
Class. 



COPYRIGHT DEPOSIT 



m 




5* 

S o 

"S Si 



PHYSICAL DIAGNOSIS 



BY 

RICHARD C. CABOT, M.D. 

INSTRUCTOR IN MEDICINE IN HARVARD UNIVERSITY 



TOirfc JECution, IRewsefc anfc lEnlargefc 



WITH FIVE PLATES, AND TWO HUNDRED AND FORTY FIGURES 
IN THE TEXT 



NEW YORK 
WILLIAM WOOD AND COMPANY 

MDCCCCV 



{LIBRARY of JONGHtSS 
Two iopies rfeceiveu 

AU§ 1 1905 
GLASS » AK& Ma 






COP* 8. 




Copyright, 1905, 
By WILLIAM WOOD AND COMPANY. 



TO 

FEEDEKICK C. SHATTUCK, M.D. 

Jackson Professor of Clinical Medicine 
in Harvard University 

IN EVIDENCE OF MY APPRECIATION OF 

THE EXAMPLE OF SINCERITY, COMMON SENSE, AND ENTHUSIASM 

ESTABLISHED BY HIM IN THE TEACHING AND 

THE PRACTICE OF MEDICINE 



PREFACE. 



This book endeavors to present an account of the diagnostic 
methods and processes needed by competent practitioners of the 
present date. It differs from other books on the subject in that it 
makes no attempt to describe technical processes with which the 
writer has no personal familiarity and gives no space to the descrip- 
tion of tests which he believes to be useless. 

To gain genuine familiarity with all the technical processes de- 
scribed in most books on physical diagnosis — such familiarity as 
makes one competent to use them with due regard for the sources 
and limits of error inherent in them — needs more than the life-time 
of one man. But unless one has one's self used a technical process 
long enough to gain this sort of mastery over it, one cannot prop- 
erly describe it, far less recommend it to others. Because of my lack 
of personal acquaintance with such methods as cystoscopy, ophthal- 
moscopy, and laryngoscopy I have attempted no description of them, 
although I believe they should sooner or later be mastered by every 
internist. All that I have described I know by prolonged use. 

A book constructed on this basis should make obvious what its 
writer considers important and what unimportant, and reveal 
therein not only his opinions but his personal limitations. Bat I 
believe there is no longer a demand for books that attempt impar- 
tially to present all that has been or is now thought of value by 
some one. The personal equation cannot and should not be ig- 
nored. In diagnosis as in therapeutics " What do you find valua- 
ble ? " is the question that our contemporaries ask of any one of us, 
not " What has been recommended ? " 

In the endeavor further %o break down the false distinction be- 



VI PREFACE. 

tween clinical diagnosis and laboratory diagnosis I have described 
all the methods of getting at an organ — e.g., the kidney — in a sin- 
gle section. Palpation, thermometry, urinalysis are different proc- 
esses by which we may gather information about the kidney. The 
student should be accustomed to think of them and practise them 
in close sequence. 

For the same reason the most important methods of investigat- 
ing the stomach have been grouped together without any distinction 
of "clinical" and "laboratory" procedure. 

For the illustrations I owe many thanks to many persons, espe- 
cially to Drs. Frank Billings, A. E. Boycott, E. G. Bradford, E. 
E. Carson, J. Everett Dutton, K. T. Edes, Joel E. Goldthwaite, 
J. S. Haldane, Frederick T. Lord, R. W. Lovett, H. C. Masland, 
S. J. Meltzer, Percy Musgrave, R. F. O'Neil, J. E. Schadle, Will- 
iam H. Smith, W. S. Thayer, and G. L. Walton ; also to the edi- 
tors of the Boston Medical and Surgical Journal, the St. Paul 
Medical Journal, American Medicine, The Journal of Experimental 
Medicine, and The Lancet. 

My assistant, Dr. Mary W. Rowley, has helped me very much 
with the index as well as with other parts of the book. 

190 Marlboro St., Boston. 
June, 1905. 



TABLE OF CONTENTS. 



CHAPTER I. 
DATA RELATING TO THE BODY AS A WHOLE. 

PAGE 

1. Weight, 1 

(a) Causes of Gain in Weight, 1 

(b) Causes of Loss in Weight, 2 

2. Temperature — Technique and Sources of Error, ... 2 

(a) Causes of Fever, 2 

(b) Types of Fever,' 2 

(c) Subnormal Temperature, 2 

(d) Chills and Their Causes 2, 3 

CHAPTER II. 
DISEASES OF THE HEAD, FACE, AND NECK. 

I. The Cranial Vault 5 

1. Size, Shape, ; . 5 

2. Fontanels, 6 

3. Hair, 7 

II. The Forehead, 8 

III. The Face as a Whole 9 

IV. Movements of the Head and Face, 13 

V. The Eyes, 13 

(a) Ocular Motion, 16 

(b) The Retina, 16 

VI. The Nose, 17 

VII. The Lips 18 

VIII. The Teeth, 20 

IX. The Breath, 21 

X. The Tongue, 22 



Vlll 



TABLE OF CONTENTS. 



PAGE 

- XI. The Gums, 24 

XII. The Buccal Cavity, 25 

XIII. The Tonsils and Pharynx, 26 

XIV. The Neck, 29 

(a) Glands, 29 

(b) Abscess or Scars, 31 

(c) Tumors and Cysts, . 31-34 

(d) Vertebral Tuberculosis, .33 

(e) Actinomycosis, 34 

(/) Cervical Rib, 34 



CHAPTER III. 



THE ARMS AND HANDS; THE BACK. 

The Arms. 

I. Paralysis 35 

II. Wasting of One Arm, 37 

III. Contractures, 37 

IV. (Edema, 38 

V. Tumors, 38 

VI. Miscellaneous Lesions of the Forearm, 40 

The Hands 41 

I. Evidence of Occupation, . 41 

II. Temperature and Moisture, 42 

III. Movements, 42 

IV. Deformities, . . 46 

The Nails, 52 

The Back, 53 

I. Stiff Back, . . . . . . ■ 53 

II. Sacroiliac Disease, 53 

III. Spinal Curvature, . . . . - 54 

IV. Tumors of the Back, . . . 54 

V. Prominent Scapula, . . . 55 

VI. Spina Bifida, 55 



TABLE OF CONTENTS. 



IX 



CHAPTER IV. 

THE CHEST. 

TECHNIQUE AND GENERAL DIAGNOSIS. 



Introduction, 

I. Methods of Examining the Thoracic Organs, 
II. Regional Anatomy of the Chest, 



PAGE 

. 56 
. 56 
. 56 



INSPECTION. 



I. Size, 



II. Shape, .... 

(a) The Rachitic Chest, . 

(b) The Paralytic Chest, 

(c) The Barrel Chest, 

III. Deformities, 

(a) Curvature of the Spine, 

(b) Flattening of One Side of the Chest, 

(c) Prominence of One Side of the Chest, 

(d) Local Prominences, . 

IV. Respiratory Movements, 

(a) Normal Respiration, 

(b) Anomalies of Expansion, . 

1. Diminished Expansion, 

2. Increased Expansion, 

(c) Dyspnoea, .... 

V. The Respiratory Rhythm, . 

(a) Asthmatic Breathing, 
(5) Cheyne-Stokes Breathing, 

(c) Restrained Breathing, 

(d) Shallow and Irregular Breathing 

(e) Stridulous Breathing, 

VI. Diaphragmatic Movements (Litten's Phenomenon) 

VII. The Cardiac Movements, 

1. Normal Cardiac Impulse, . 

2. Displacement of the Cardiac Impulse 

3. Apex Retraction, .... 

4. Epigastric Pulsation, 

5. Uncovering of the Heart, . 



60 

61 
62 
63 
64 



67 
68 

69 
69 
69 
70 
71 
71 

74 
74 
74 
75 
75 
76 

76 

79 
79 

82 
84 
85 
85 



X TABLE OF CONTENTS. 

PAGE 

VIII. Aneurism and Other Causes op Abnormal Pulsations of 

the Chest Wall, 86 

IX. The Peripheral Vessels 87 

(a) Venous Phenomena, . . . . . . . .88 

(b) Arterial Phenomena, 89 

(c) Capillary Phenomena, .91 

X. The Skin and Mucous Membranes, 92 

1. Cyanosis, 92 

2. (Edema, 93 

3. Pallor, 93 

4. Jaundice, 93 

5. Scars and Eruptions, 94 

XL Enlarged Glands, 94 



CHAPTER V. 
PALPATION AND STUDY OF THE PULSE. 

I. Palpation 96 

1. The Cardiac Impulse, 96 

2. Thrills, 97 

3. Tactile Fremitus, 98 

4. Friction, Pleural or Pericardial, . . . . . .99 

5. Palpable Rales, 101 

6. Tender Points, 102 

7. Abnormal Pulsations, . . . . . . . . 102 

8. Tumors 102 

9. Temperature and Quality of the Skin 103 

II. The Pulse, 103 

1. The Rate, . 105 

2. Rhythm, . . .105 

3. Compressibility, 106 

4. Size and Shape of Pulse Wave, . . . . . . 106 

5. Tension, 108 

6. Size and Position of Artery, 109 

7. Condition of Artery Walls, 110 

III. Arterial Pressure and the Instruments for Measuring It, 111 

1. Gaertner's Tonometer 112 

2. The Riva-Rocci Instrument, 113 

3. The Instrument of Hill and Barnard, 114 

4. The Oliver Instrument, 115 



TABLE OF CONTENTS. xi 

CHAPTER VI. 
PERCUSSION. 

PAGE 

I. Technique, .... 118 

, v j Mediate Percussion, / ^g 

^ a ' ( Immediate Percussion, . . . . . . j" 

(b) Auscultatory Percussion, 125 

(c) Palpatory Percussion, 127 

II. Percussion-Resonance of the Normal Chest, .... 127 

(a) Vesicular Resonance, 128 

(b) Dulness and Flatness, 129 

(c) Tympanitic Resonance, 130 

(d) Cracked-pot Resonance, 134 

(e) Amphoric Resonance, 135 

(/) The Lung Reflex, 136 

III. Sense of Resistance, 136 



CHAPTER VII. 
AUSCULTATION. 

1. Mediate and Immediate Auscultation, 137 

2. Selection of a Stethoscope, .138 

3. The Use of the Stethoscope . . . 143 

A. Selective Attention and What to Disregard, . . . . . . 143 

B. Muscle Sounds 146 

C. Other Sources of Error, 147 

4. Auscultation of the Lungs, . 149 

I. Respiratory Types 150 

(a) Vesicular Breathing, ........ 151 

(ft) Tubular Breathing, . .153 

(c) Broncho-vesicular Breathing, 154 

(d) Emphysematous Breathing, 155 

(e) Asthmatic Breathing, 155 

(/) Cog-wheel Breathing, 156 

(g) Amphoric Breathing, 156 

{h) Metamorphosing Breathing, 156 

II. Differences between the Right and the Left Chest, . . . 157 



Xll 



TABLE OF CONTENTS. 



III. 



IV. 

V. 

VI. 

VII. 



VIII. 

IX. 

X. 



XI. 



PAGE 

Pathological Modifications of Vesicular Breathing, . . . 157 

(a) Exaggerated Vesicular Breathing, 157 

(b) Diminished Vesicular.Breathing, 158 

Bronchial Breathing in Disease 160 

Broncho-vesicular Breathing in Disease, 160 

Amphoric Breathing, 161 

Rales, 161 

(a) Moist, 161 

(b) Dry, 162 

(c) Musical, , . .164 

Cough. Effects on Respiratory Sounds, 165 

Pleural Friction, 165 

Auscultation of the Voice Sound, 167 

(a) The Whispered Voice, 167 

(b) The Spoken Voice, 168 

(c) Egophony, 169 

Phenomena Peculiar to Pneumo-hydrothorax, .... 169 

(a) Succussion, 169 

(b) Metallic Tinkle, 170 

(c) The Lung Fistula Sound, 170 



CHAPTER VIII. 



AUSCULTATION OF THE HEART. 



1. The Valve Areas, 

2. Normal Heart Sounds, 



3. Modifications in the Intensity of the Heart Sounds, 



(a) Mitral First Sound, 

1. Lengthening, 

2. Shortening, 

3. Doubling, 

(b) The Second Sounds at the Base of the Heart, 

1. Physiological Variations, .... 

2. Pathological Variations, .... 

(a) Accentuation of Pulmonic Second Sound ; 

(b) "Weakening of Pulmonic Second Sound, 

(c) Accentuation of the Aortic Second Sound 

(d) Weakening of the Aortic Second Sound, 

(e) Accentuation of Both Second Sounds, 
(/) Summary, 



171 

172 

174 
175 
175 
175 
176 
176 
176 
178 
178 
179 
179 
179 
180 
180 



TAbLE OF CONTENTS. xiii 

PAGE 

(c) Modifications in Rhythm of Cardiac Sounds and Doubling of 

Second Sounds, 181 

(d) Metallic Quality of the Heart Sounds, ...... 182 

(e) " Muffled " Heart Sounds, ........ 182 

4. Sounds Audible Over the Peripheral Vessels. . . .182 

(a) Arterial Sounds, 182 

(b) Venous Sounds, 183 

CHAPTER IX. 

(Auscultation of the Heart, Continued.) 

CARDIAC MURMURS. 
I. Terminology, 184 

1. Mode of Production, 184 

2. Place of Murmurs in the Cardiac Cycle, 186 

3. Point of Maximum Intensity, 187 

4. Area of Transmission, 188 

5. Intensity, Quality, and Length, 190 

6. Relation to Heart Sounds, . 193 

7. Effects of Respiration, Exertion, and Position, .... 193 

8. Metamorphosis of Murmurs, 194 

II. Functional Murmurs, 194 

III. Cardio-Respiratory Murmurs, . . . . . . . . 197 

IV. Venous Murmurs, . 198 

V. Arterial Murmurs, 198 

CHAPTER X. 
DISEASES OF THE HEAET. 

VALVULAR LESIONS. 

1. Valvular and Parietal Disease, 199 

2. The Establishment and Failure of Compensation, . . . 202 

3. Hypertrophy and Dilatation, 205 

4. Valvular Disease, 210 

I Mitral Regurgitation, 210 

(a) Pre-compensatory Stage, . . . ... . 212 

(b) Stage of Compensation, . 213 



xiv TABLE OF CONTENTS. 

PAGE 

(c) Stage of Failing Compensation, 217 

(d) Differential Diagnosis, 218 

II. Mitral Stenosis, 220 

1. First Stage, . . . 222 

2. Second Stage, . . 224 

3. Third Stage, 225 

4. Differential Diagnosis 226 

III. Aortic Regurgitation, 229 

1. Inspection, 230 

(a) Arterial Jerking, 231 

(b) Capillary Pulsation, 232 

2. Palpation, 233 

3. Percussion 234 

4. Auscultation, 234 

5. Summary and Differential Diagnosis, 237 

6. Prognosis, ■ . . . .238 

7. Complications, 238 

IV. Aortic Stenosis, 239 

1. (a) The Murmur, . . .240 

(b) The Pulse, 242 

(c) The Thrill, 243 

(d) Feeble Aortic Second Sound, 244 

2. Differential Diagnosis, 243 

V. Tricuspid Regurgitation, . . . . . . . . . 246 

1. (a) The Murmur, 247 

(b) Venous Pulsation, 247 

(c) Cardiac Dilatation 248 

(d) Feeble Pulmonic Second Sound, 248 

2. Differential Diagnosis, 249 

VI. Tricuspid Stenosis, 250 

VII. Pulmonary Regurgitation, 251 

VIII. Pulmonary Stenosis, . 252 

IX. Combined Valvular Lesions, . . 253 

(a) Double Mitral Disease, . . . . . . . 254 

(b) Aortic and Mitral Regurgitation, 255 

(c) Aortic Stenosis and Regurgitation 256 

CHAPTER XI. 

PARIETAL DISEASE AND CARDIAC NEUROSES. 

I. Parietal Disease of the Heart, 257 

1. Acute Myocarditis, ........ 257 



TABLE OF CONTENTS. 



xv 



PAGE 

2. Chronic Myocarditis, 258 

3. Fatty Overgrowth, 260 

4. Fatty Degeneration, 260 

II. Cardiac Neuroses, 261 

1. Tachycardia, 261 

2. Bradycardia, 262 

3. Arrhythmia, 263 

4. Palpitation, 264 

III. Congenital Heart Disease, 265 



CHAPTER XII. 



DISEASES OF THE PERICARDIUM. 



I. Pericarditis, 



(a) Dry or Fibrinous, .... 

(b) Pericardial Effusion, 

1. The Area of Dulness, . 

2. The Cardiac Impulse and the Pulse, 

3. Pressure Signs, .... 

(c) Adherent Pericardium, 

1. 
2. 
3. 
4. 
5. 



Retraction of Interspaces, . . . 

Limitation of Respiratory Movements, 

Absence of Cardiac Displacement with Change of Position, 

Hypertrophy and Dilatation not Otherwise Explained, 

Capsular Cirrhosis of the Liver, 



268 
271 

272 
274 
274 
276 
276 
277 
277 
277 
277 



CHAPTER XIII. 



THORACIC ANEURISM. 

Abnormal Pulsation, . 280 

Tumor, .281 

Thrill, ; 282 

Diastolic Shock, 282 

Tracheal Tug, 283 

Pressure Signs, 284 

Percussion Dulness, 284 

Auscultation, 285 

(a) Murmurs, . . 285 

(b) Diastolic Shock Sound, 286 



xvi TABLE OF CONTENTS. 

PAGE 

9. Radioscopy, 287 

10. Summary, 287 

11. Diagnosis, 288 

CHAPTER XIV. 

DISEASES OF THE LUNGS AND PLEURA. 

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 

1. Tracheitis, 292 

2. Bronchitis, 292 

(a) Physical Signs, 293 

(b) Differential Diagnosis, 294 

3. Croupous Pneumonia, 296 

(a) Inspection, 296 

(b) Palpation, 297 

(c) Percussion, 297 

(d) Auscultation, . . . 298 

(e) Summary, " . . 301 

(/) Differential Diagnosis, 301 

4. Broncho-Pneumonia, . . . . 302 

5. Pulmonary Tuberculosis, 304 

(a) Incipient Tuberculosis, 304 

(b) Moderately Advanced Cases, 308 

(c) Advanced Phthisis, 311 

(d) Anomalous Forms of Pulmonary Tuberculosis, .... 315 

CHAPTER XV. 

v dlseases of the lungs, continued.) 

1. Emphysema, 317 

(a) Small-Lunged Emphysema, 317 

(b) Large-Lunged Emphysema, 317 

(c) Emphysema with Bronchitis and Asthma, 320 

{d) Interstitial Emphysema, 321 

(e) Complementary Emphysema, 321 

(/) Acute Pulmonary Tympanites, 321 

2. Bronchial Asthma, 322 



TABLE OF CONTENTS. XVll 

PAGE 

3. Syphilis of the Lung, . . .323 

4. Bronchiectasis, 323 

5. Cirrhosis of the Lung, . 324 

6. Examination of Sputa, 324 

(a) Origin, 324 

(b) Odor and Appearances 325 

(c) Staining . .326 

(d) Microscopic Examination, . 327 

(e) Description of Commoner Organism, 328 

CHAPTER XVI. 
DISEASES AFFECTING THE PLEURAL CAVITY. 

I. Hydrothorax, . . 330 

II. Pneumothorax, 330 

III. Pneumoserothorax and Pneumopyothorax, ..... 332 
Differential Diagnosis of Pneumothorax and Pneumohydrothorax, . 334 

IV. Pleurisy, . . . .336 

1. Dry Pleurisy, 336 

2. Pleuritic Effusion, 338 

(a) Percussion, . . 339 

(b) Auscultation. 345 

(c) Inspection and Palpation, 347 

3. Pleural Thickening, . . . . . . . . . .349 

4. Encapsulated Pleural Effusions, . . . . . . . 349 

5. Pulsating Pleurisy and Empyema Necessitatis 350 

6. Differential Diagnosis of Pleural Effusions, 350 

V. Cyto-Diagnosis of Pleural and Other Fluids, 353 

(a) Technique, 354 

{b) Interpretation of Results, 355 

CHAPTER XVII. 

ABSCESS, GANGRENE, AND CANCER OF THE LUNG, PULMO- 
NARY ATELECTASIS, GEDEMA AND HYPOSTATIC 
CONGESTION, 

1. Abscess and Gangrene of the Lung, 357 

2. Cancer of the Lung, 358 

3. Atelectasis, , 359 

4. (Edema and Hypostatic Congestion, . 360 



xvm TABLE OF CONTENTS. 



CHAPTER XVIII. 

THE ABDOMEN IN GENERAL, THE BELLY WALLS, PERITO- 
NEUM, OMENTUM, AND MESENTERY. 

PAGE 

Examination of the Abdomen in General, 362 

1. The Omentum, Mesentery, and Peritoneum, ..... 362 

2. Technique, 362 

3. Inspection, 363 

4. Palpation, . . 364 

5. What can be felt Beneath the Normal Abdominal Walls, . . 365 

6. Palpable Lesions of the Belly Walls, .367 

7. Abdominal Tumors, . 368 

8. Percussion, 370 

Diseases of the Peritoneum, 370 

1. Peritonitis, Local or General, . . 371 

2. Ascites, 372 

3. Cancer and Tuberculosis, 372 

The Mesentery, 373 

1. Glands, 373 

2. Thrombosis, . . .373 



CHAPTER XIX. 

THE STOMACH, LIVER, AND PANCREAS. 

The Stomach, 374 

1. Inspection and Palpation, 374 

2. Estimation of the Size, Position, Secretory and Motor Power. . 376 

3. Examination of Contents, 379 

(a) Qualitative Tests, 380 

(b) Quantitative Estimation of Free HC1 and of Total Acidity, . 380 

4. Incidence and Diagnosis of Gastric Diseases, . . . . . 382 

The Liver, 384 

(ffi)-Pain, s ' 385 

(b) Enlargement, 386 

(c) Atrophy, .389 

(d) Portal Obstruction, v . .389 

(e) Jaundice, 390 

(/) Loss of Flesh and Strength, ... .392 

(g) The Infection Group of Symptoms, 392 

(Ji) Cerebral Symptoms of Liver Disease, ...... 393 



TABLE OF CONTENTS. XIX 

PAGE 

The Gall Bladder and Bile Ducts, 393 

1. Differential Diagnosis of Biliary Colic, 393 

2. Enlarged Gall Bladder, 394 

3. Cholecystitis 394 

4. Results of Cholecystitis, 395 

The Pancreas, 395 

1. Cancer, ' . ' 396 

2. Acute Pancreatic Disease, 396 

3. Cyst, 396 

4. Bronzed Diabetes, . 396 



CHAPTER XX. 
THE INTESTINES, SPLEEN, AND KIDNEY. 

The Intestines, 397 

1. Data for Diagnosis 397 

2. Appendicitis, 399 

3. Obstruction, . . . . . . . . . . .401 

4. Cancer, 402 

5. Examination of Contents, 402 

6. Parasites, 404 

The Spleen, • . 410 

1. Palpation, 410 

2. Percussion, ■ . . . . 412 

3. Causes of Enlargement, 412 

4. Differential Diagnosis of the Various Causes of Enlargement, . 413 

The Kidney, 414 

1. Incidence and Data, . . . 414 

2. Characteristics Common to Most Tumors of the Kidney, . . 415 

3. Malignant Disease, 415 

4. Hydronephrosis and Cystic Kidney* 415 

5. Perinephritic Abscess, 416 

6. Abscess of the Kidney, 416 

7. Floating Kidney, 417 

8. Renal Colic and Other Renal Pain, 417 

9. Examination of the Urine, 418 

(a) Amount and Weight, 419 

(b) Optical Properties, 420 

(c) Significance of Sediments (Gross) 421 

10. Pyuria, 421 



xx TABLE OF CONTENTS. 

PAGE 

11. Hematuria, , 422 

12. Chemical Examination of the Urine, 423 

(a) Reaction of Normal Urine. 423 

(b) Tests for Albuminuria, 424 

13. Significance of Albuminuria, 425 

14. Glucosuria and Its Significance, 426 

15. The Acetone Bodies, 428 

16. Other Constituents, 428 

17. Microscopic Examination of Urinary Sediments, .... 429 

18. Summary of the Urinary Pictures Most Useful in Diagnosis, . 434 

CHAPTEE XXI. 
THE BLADDER, RECTUM, AND GENITAL ORGANS. 

The Bladder, 437 

1. Incidence and Data 437 

2. Distention, 437 

3. The Urine as Evidence of Bladder Disease, 439 

The Rectum, 440 

1. Symptoms which should Suggest an Examination, . . . .440 

2. Methods, . . . . . . 441 

3. Results, 441 

The Male Genitals, . . 442 

1. The Penis, .443 

2. The Testes and Scrotum, 444 

The Female Genitals, 445 

1. Methods, 445 

2. The External Genitals, 446 

3. The Uterus, 447 

4. The Fallopian Tubes. ......... 448 

5. The Ovaries, 449 



CHAPTEE XXII. 
THE LEGS AND FEET. 

The Legs, 452 

I. Hip, 452 

II. Groin, 452 

III. Thigh 453 

IV. Knee 458 



TABLE OF CONTENTS. xxi 

PAGE 

V. (a) Lower Leg, . 458 

(b) The Feet, 460 

(c) The Toes, 463 



CHAPTER XXIII. 
THE BLOOD. 

Examination of the Blood, . 464 

1. Haemoglobin, 464 

2. Study of the Stained Blood Film, 467 

3. Counting the White Corpuscles, 473 

4. Counting the Ked Corpuscles, 474 

5. Interpretation of These Data, 475 

(a) Secondary Anaemia, 475 

(b) Chlorosis, . . . . . 476 

(c) Pernicious Anaemia, . . . . . . . . . 476 

(d) Leucocytosis, 477 

(e) Lymphocytosis, 479 

(/) Eosinophilia, 479 

(g) Leukaemia, 480 

6. The Widal Reaction, .481 

7. Blood Parasites, 482 

(a) Malaria, 482 

(b) Trypanosoma, 483 

(c) Filaria, . . . 483 

8. Estimation of Coagulation Time, 485 

CHAPTER XXIV. 

THE JOINTS. 

Examination of the Joints, 486 

1. Methods and Data, 486 

2. Technique, 487 

Joint Diseases, 491 

1. Infectious Arthritis, 492 

2. Atrophic Arthritis, 496 

3. Hypertrophic Arthritis, 498 

4. Gouty Arthritis, 501 

5. Hemophilic Arthritis, 503 

6. Relative Frequency of the Various Joint Lesions, .... 504 



/XX11 



TABLE OF CONTENTS. 



CHAPTER XXV. 
THE NERVOUS SYSTEM. 

PAGE 

Examination of the Nervous System, 505 

I. Disorders of Motion, 505 

II. Disorders of Sensation, 509 

III. Reflexes, 510 

IV. Electrical Reactions, . . 515 

V. Speech and Handwriting, 516 

VI. Trophic Vasomotor Disorders, 517 

VII. The Examination of Psychic Functions; Coma, . . . 517 



APPENDICES. 

Appendix A. — Diseases op the Mediastinum, 

1. Mediastinal Tumors, .... 

2. Mediastinitis, 

3. Tuberculosis of Mediastinal Glands, 

Appendix B. — Acute Endocarditis, 
Appendix C. — Examination of Infants' Chests, 
Appendix D. — Radioscopy of the Chest, 
Appendix E. — The Sphygmograph, 



521 
521 
524 
524 

525 

526 
527 
534 



PHYSICAL DIAGNOSIS. 



CHAPTER I. 

DATA RELATING TO THE BODY AS A 
WHOLE. 

I. WEIGHT. 

To weigh the patient should be part of every physical examina- 
tion, and every physician's office should contain a good set of 
scales. 

1. Gain in weight, aside from seasonal changes, the increase in 
normal growth, and convalescence from wasting diseases, means 
usually : 

(a) Obesity. 

(b) The accumulation of serous fluid in the body — dropsy, evi- 
dent or latent. 

The first of these needs no comment. Latent accumulation of 
fluid, not evident in the subcutaneous tissues or serous spaces, oc- 
curs in some forms of uncompensated cardiac or renal disease, and 
gives rise to an increase in weight which may delude the physician 
with the false hope of an improvement in the patient's condition, 
but in reality calls for derivative treatment (diuresis, sweating). 

Obvious dropsy has, of course, the same effect on the weight 
and the same significance. 

(c) Myxoedema is occasionally a cause of increased weight, i.e., 
when the myxedematous infiltration is widespread (see below, page 
10). 



2 PHYSICAL DIAGNOSIS. 

2. Loss of Weight. — The aging process is so often associated 
with loss of weight that some writers speak of the u cachexia of old 
age." In some, a rapid loss of superfluous fat may occur at moder- 
ate age, e.g., at fifty -five, and may give rise to grave apprehension 
though the general health remains good and no known disease de- 
velops. 

Aside from this physiological change of later life, most cases of 
loss of weight are due to : 

(a) Malnutrition. 

(b) Loss of sleep (whether from pain or other cause). 

(c) Infectious fevers and other toxsemic states. 

Under the head of malnutrition come the cases of oesophageal 
stricture, chronic dyspepsia (with or without gastric ulcer or dila- 
tation) and gastric cancer, chronic diarrhoea, the atrophies of in- 
fancy, diabetes mellitus, and the rare cases of anorexia nervosa. 

Loss of sleep is, I believe, the chief factor in the emaciation oc- 
curring in many painful illnesses as well as in various other types 
of disease. It is only in this way that I can account for the marked 
emaciation in many cases of thoracic aneurism. 

Toxcemia is, I suppose, accountable for part at least of the ema- 
ciation in typhoid, cirrhotic liver, and tuberculosis. 

II. TEMPERATURE. 

The method of taking temperature is too familiar to need expla- 
nation, but the student should be aware of the fact that hysterics 
and malingerers can and often do raise the mercury in the bulb by 
various manoeuvres, unless they are vigilantly watched. Dipping 
the bulb into hot water, shaking the mercury upward toward the 
higher degrees of the scale, and possibly friction with the tongue 
(?) are to be suspected. 

In comatose patients and in infancy the temperature is best 
taken by rectum. In others we must be sure that the lips do not 
remain open during the test, so as to reduce the temperature of the 
mouth. 

1. Fever, i.e., a temperature above 99.5° F., in adults has much 



TEMPERATURE. 6 

more diagnostic value than in infancy and childhood. In the lat- 
ter it is often impossible to make out any pathological condition to 
account for a fever. After childhood the vast majority of fevers 
are found to be due to : 

(a) Infectious disease or inflammation of any type. 

(b) Toxaemia without infection — a much less common and less 
satisfactory explanation. * 

(c) Disturbance of heat regulation — as in sunstroke, after the 
use of atropine, and in nervous excitement, e.g., just after entering 
a hospital. 1 

For such causes we search when the thermometer indicates 
fever. 

Types of fever often referred to are : 

(a) " Continued fever '" one which does not return to normal at 
any period in the twenty-four hours, as in many cases of typhoid, 
pneumonia, and tuberculosis. 

(b) "Intermittent" "hectic " or "septic" fever, one which disap- 
pears once or more in twenty-four hours, as in double tertian mala- 
ria and septic fevers of various types (including mixed infections in 
tuberculosis). 

A fever which disappears suddenly and permanently is said to 
end by "crisis" while one which gradually p esses off in the course 
of several days ends by " lysis" 

2. Subnormal temperature is often seen in wasting disease (can- 
cer), nephritis, uncompensated heart disease, and myxcedema. It 
is rarely of diagnostic value, but is a rough measure of the degree 
of prostration. 

3. Chills (due usually to a sudden rise in temperature) are seen 
chiefly in : 

(a) Sepsis of any type. 
lb) Malaria. 

(c) Onset of acute infections. 

(d) "Nervous" states. 

After the passage of a catheter, after or during labor, and after 

1 The latter event may also reduce (temporarily) a high fever to normal or 
below it. 



4 PHYSICAL DIAGNOSIS. 

infusion of saline solution, a chill is often seen, but not easily ex- 
plained. 

True chill, with shivering and chattering teeth, is distinguished 
from chilliness without any shivering. Chilliness is far less signifi- 
cant and often goes without fever; true chill rarely does. 

The cause of true chills can usually be determined by blood 
examination (leucocytosis, malarial parasites) and by the general 
physical examination. 



CHAPTER II. 



THE HEAD AND FACE; THE NECK, 



THE HEAD AND FACE. 



Almost all that we can learn about the manifestations of dis- 
ease on the head and face is to be learned by the use of our eyes, 

by inspection, as the term is. Other 
methods — percussion, cc-ray, palpa- 
tion — yield but little. I shall begin 
at the top. 

I. The Cranial Vault. 

1. The Shape and Size of the 
Cranium. 

The shape and size of the cranium 
concern us, especially in children. 

(a) Abnormally small crania (mi- 
crocephalia) are apt to mean idiocy, 
especially if the sutures are closed. 

(&) An abnormally large head is 
seen in hydrocephalus (see Fig. 1), 
associated with enormous " open " 
areas uncovered by bone and a pe- 
culiar downward inclination of the 
eyes, which are partly covered by the eyelids and show a white 
margin above the iris. This condition is to be distinguished from the 




Fig. 1.— Hydrocephalus. 



6 PHYSICAL DIAGNOSIS. 

(c) Rachitic head, which is flatter at the vertex and more pro- 
tuberant at the frontal eminences, giving it a squarish outline, con- 
trasted with the globular shape and rounded vertex of the hydro' 
cephalic. In rickets there are no changes in the eyes. 

(d) In adult life an enlargement of the skull, due to bony thick- 





FIG. 



-Paget's Disease. (Edes.) a, Before onset of hyperostosis cranii. 
perostosis cranii. 



b, After onset of hy- 



ening, forms part of the rare disease, osteitis deformans (Paget's 
disease), associated with thickening and bowing of the long bones 
(see Fig. 2). 

2. The Fontanels. 



The anterior and larger fontanel remains about the same size for 
the first year of life, then diminishes, and closes about the twenti- 
eth month. The posterior closes in about six weeks. In rickets, 
hydrocephalus, hereditary syphilis, and cretinism, the fontanels 
and sutures remain open after the normal time limit. 

(a) Bulging fontanels mean increased intracranial tension (hy- 
drocephalus, hemorrhage, meningitis, or any acute febrile disease 
without dyspnoea), (b) Depressed fontanels are seen in severe diar- 



THE HEAD AND FACE. ( 

rhcea, wasting diseases, collapsed states, and acute dyspnoeic condi- 
tions. 

3. The Hair. 

(a) A rachitic child often rubs the hair off the back of its head 
by constant rolling on the pillow. (This is associated with profuse 




Fig. 3.— Syphilis of the Frontal Bone. (Curschmann.) 

sweating of the head.) Patchy baldness occurs in the skin disease 
alopecia areata, and occasionally over the painful area in trigem- 
inal neuralgia. 

(b) General loss of hair occurs normally after many acute fevers 
and with advancing age. Early baldness (under thirty-five) is often 
hereditary. Syphilis may produce a rapid loss of hair, local or 



8 



PHYSICAL DIAGNOSIS. 



general, and the same is true of myxoedema; but in both these dis- 
eases the hair usually grows again in convalescence. 

(c) Parasites (pediculi) are worth looking for in the dirtier 
classes and those associated with them (teachers). Their eggs ad- 




Fig. 4,— Acromegalia. 



here to the hairs and are familiarly known as "nits. 
or itching dermatitis often results. 



An eczema 



II. The Forehead. 



Scars, eruptions, and bony nodes are important. 
(a) Scars may be due to trauma or to old syphilitic periostitis. 
The epileptic often cuts his forehead in falling. 



THE HEAD AND FACE. 



9 



(li) Eruptions often seen on the forehead are those of acne ? 
syphilis, and smallpox. These may resemble each other closely, 
and are to be distinguished by the history, the presence of lesions 




Fig. 5.— Typical Face in Acromegaly. 



on other parts of the body, and the concomitant signs (fever, pros- 
tration, etc.). 

(c) Nodes may be the result of many bumps in childhood or may 
be caused by a syphilitic periostitis (see Fig. 3). The history must 
decide. 

III. The Face as a Whole. 

Very characteristic even at a glance is the face of (</) acrome- 
galia, A strong family likeness seems to pervade all well-marked 



10 



PHYSICAL DIAGNOSIS. 



cases (see Figs. 4 and 5). The huge, bony " whopper jaw" is the 
most striking item, then the prominent cheek bones, and the ridge 
above the eyes. The nose and chin are very large. 

(b) Myxcedema (see Fig. 6) is not so characteristic and might 
easily be mistaken for nephritis or normal stupidity with obesity. 
The presence of dry skin, falling 
hair, mental dulness, and subnormal 



temperature, 
taneously within 



supervening simul- 




FiG. 6.— Myxoedema. 



Fig. 7.- -Cretinism. 



months, make us suspect the disease. Palpation shows that the 
puffiness of the face is not true oedema, as it does not pit on press- 
ure. 

(c) Cretinism— -the infantile form of myxcedema — can generally 
be recognized by sight alone (see Fig. 7). Here the tongue is 
often protruded, and there are often pot-belly and deformed legs. 

(d) In adenoids of the nasopharynx the child's mouth is often 
open, the nose looks pinched, the expression is stupid (see Fig. 8). 



THE HEAD AND FACE. 



11 



There is a history of mouth-breathing and snoring, with frequent 
"colds," a high-arched palate, and perhaps deafness. 

(e) In paralysis agitans the " mask-like " face shows almost no 
change of expression, whatever the patient says or does. The neck 
is usually inclined forward, and so rigid that when the patient 




Fig. 8.— Adenoid Face. (Schadle.) 



wishes to look to right or left his whole body rotates like a statue 
on a pivot. 

(/) In Graves' disease (exophthalmic goitre) the startled or 
frightened look is characteristic, though the expression is almost 
wholly due to the bulging of the eyes and their quick motions 
(Fig. 9). 

(g) In leprosy the general expression is of a superabundance of 
skin on the patient's face, reminding us of some animal ("leonine 
face") (Fig. 10). 

(Ji) In early phthisis one often notices the clear, delicate skin, 



12 



PHYSICAL DIAGNOSIS. 



fine hair, long eyelashes, wide pupils — ''appealing eyes." Pallor 
and a febrile flush (hectic) come later in some cases. 

(/) After vomiting the face has often a drawn, pinched, anxious 
look, which has often been supposed to be characteristic of general 
peritonitis, intestinal obstruction, or other diseases accompanied by 

vomiting ; but I do not recognize 
any single expression as charac- 
teristic of peritoneal lesions. 
(,/) Chronic alcoholism may 




Fig. 9.— Exophthalmic Goitre. (Meltzer.) 



Fig. 10.— Face in Leprosy. 



be shown not only in a red nose, but oftener in a peculiar, smoothed- 
out look, due, I suppose, to an extra but evenly distributed ac- 
cumulation of subcutaneous fat. 

(A*) An (Edematous or swollen face is much more easily noticed 
by the patient or his friends than by one who is not familiar with 
his normal look. It usually points to nephritis, but may occur in 
heart disease, and sometimes (especially in the morning) without 
any known cause. When combined with anaemia, the puffy face 
gives a peculiar " pasty " look (chronic diffuse nephritis). 



THE HEAD AND FACE. 13 

IV. Movements of the Head and Face. 

1. The Shaking Head. 

This occurs often in old age, occasionally in paralysis agitans 
(which oftener affects the hands), and in toxic conditions (alcohol, 
tobacco, opium). In some cases no cause can be found. 

2. Spasms of the Face. 

Spasms of the face, i.e., sudden, quick contractions of certain 
facial muscles, such as winking-spasm, jerking of a corner of the 
mouth, or sniffing, occur chiefly : 

(a) As a matter of habit without other disease. 

(b) As a part of the disease chorea, associated with similar 
" restless " motions of the hands and feet. We often see these 
spasms in school-children; occasionally in pregnant women. 

(^) By imitation, in schools and institutions, these spasms may 
spread like an epidemic. 

From habit spasms, which persist for months or years in one or 
two groups of muscles, true chorea is distinguished by its involve- 
ment of the hands, feet, and other parts, by its frequent association 
with joint pain and endocarditis (see page 493), and by its short 
course (eight to ten weeks on the average). 

In hysterical conditions and hereditary brain defects, various 
other spasms occur (see below, page 506). 

V. The Eyes. 

I shall not attempt to deal with lesions essentially local (such 
as a "sty"), and shall confine myself to data that have diagnostic 
value in relation to the rest of the body. 

1. (Edema of the Lids. 

(Edema of lids, especially the lower, often accumulates in the 
night and is seen in the early morning, without known cause or 



14 PHYSICAL DIAGNOSIS. 

after a debauch. In other cases it usually points to the existence 
of: 

(a) Nephritis (prove by urinary examination). 

(6) Ancemia (prove by blood examination). 

(c) Measles and whooping-cough (eruption, paroxysms of cough). 

Rarer causes are trichiniasis, angioneurotic oedema, and erysipelas. 

Trichiniasis is recognized by the presence of fever, muscular ten- 
derness, and an excess of eosinophiles in the blood. 

In angioneurotic oedema there is usually a previous history of 
similar transitory swellings in other parts of the body. 

The acute onset, red blush, high fever, and general prostration 
distinguish the oedema of erysipelas. 

2. Dark Circles under the Eyes 

may appear in any debilitated stage, e.g., from loss of sleep, hun- 
ger, menstruation, masturbation, etc. 

3. " Pink Eye " or Conjunctivitis. 

This affection forms part of hay fever, measles, yellow fever, 
and some cases of influenza. It may also occur as an independent 
infection. It follows overdoses of iodide of potash or arsenic. 
The whole conjunctiva is reddened, in contradistinction from the 
reddening about the iris seen in iritis. 

4. Jaundice. 

Jaundice, the yellow coloration of the white of the eye by bile 
pigment, is easily recognized and can be confounded only with sub- 
conjunctival fat, which differs from jaundice in that it appears in 
spots and patches, not covering the whole sclera, as jaundice does. 

The skin, mucous membranes, urine, and sweat are also bile- 
stained in most cases, and the circulation of the bile in the blood 
often produces slow pulse, itching, and mental depression. Lack of 
bile in the gut leads to flatulence and clay-colored stools. 

The commonest causes are : (a) Biliary obstruction (catarrh, 



The head and face. 15 

stone or tumors obstructing the bile ducts, hepatic cirrhosis, or 
syphilis constricting them). 

(b) Toxaemia (malaria, sepsis, icterus of the new-born, perni" 
cious anaemia). 

5. The Pupils. 

The normal reflexes to light and distance are tested as follows : 
Let the patient face the light and cover one eye with the hand. 
On withdrawing the hand, the pupil contracts. Then turn the pa- 
tient away from the light and let him look at the farthest corner of 
the room. The pupil expands. Make him look at your finger a 
few inches distant from his eyes. The pupil contracts. Each pu- 
pil should be examined separately. 

The value of the pupils in diagnosis has been greatly overesti- 
mated. There are, in fact, c6mparatively few conditions in which 
they yield us important diagnostic evidence, for, although they are 
very often abnormal, the abnormalities are seldom characteristic of 
any single pathological condition and throw little light on the diag- 
nosis. 

A. The Argyll-Robertson pupil reacts to distance, but not to 
light. It is of great value as a factor in the diagnosis of tabes dor- 
salis and dementia paralytica. 

B. Dilated Pupils. — (a) Many phthisical patients show a 
more or less transient dilatation of one or both pupils, (b) Blind- 
ness or deficient sight (from any cause) may cause dilatation of the 
pupil, (c) Other common causes are distress or strong emotion from 
any cause, many fevers and comatose states, and the use of mydri- 
atic drugs. 

C. Contracted pupils are common in old age and in photo- 
phobia from any cause. Disease high up in the spinal cord (tabes, 
general paralysis, etc.) may produce contraction {spinal myosis) by 
paralyzing the sympathetic dilators. Aortic aneurism may produce 
in the same way contraction of one pupil (see below, page 284). 

D. Contraction with irregular outline and sluggish reac- 
tions is often seen in iritis as a result of adhesions to the lens (pos- 
terior synechia?). 



16 PHYSICAL DIAGNOSIS. 



6. The Cornea. 



(a) Arcus senilis, a grayish ring at the circumference of the 
cornea, is one of the classical signs of old age and arteriosclerosis. 

{!>) Syphilitic keratitis, usually seen in the hereditary form of 
the disease, produces an irregularly distributed haziness of the cor- 
nea, usually in both eyes and before the sixteenth year. Diagnosis 
depends on other evidences of syphilis. 

VI. Ocular Motioxs. 

(a) Ptosis, or dropping of the eyelid, is usually unilateral and 
dependent on paralysis of the third nerve. Its most frequent cause 
is syphilis. The eye is usually drawn out by the action of the un- 
paralyzed external rectus. Moderate, bilateral ptosis is common in 
hysterical and neurasthenic conditions. 

(/>) Squint (strabismus) is called external if the eye turns out, 
internal if it turns in. Of its many types and causes I mention 
only the acute cases due to intracranial lesions, such as tuberculous 
and epidemic meningitis, syphilis, tumors. 

(c) Nystagmus is a rapid horizontal oscillation of both eyeballs. 
It may be the result of albinism or of various local eye troubles, but 
is an important member of the symptom group characteristic of 
multiple sclerosis. It may, however, occur in many other brain le- 
sions. 

VII. The Ketixa. 

The lesions which are of greatest interest in general medicine 
are : Retinal hemorrhage, optic neuritis, and optic atroph}\ 

(V/) Retinal hemorrhages, with or without other retinal changes, 
are important signs of nephritis, grave anosmias, and diabetes. 

(b) Optic neuritis (usually bilateral) is of great value in the 
diagnosis of brain tumors, tuberculous meningitis, and brain abscess. 
It also forms part of the lesions in many cases of nephritis and 
diabetes. 

(c) Optic atrophy may be the end result of any of the types of 
optic neuritis just mentioned, or in a primary form is important 



THE HEAD AND FACE. 17 

evidence of tabes clorsalis. Many cases occur without any known 
cause. 

VIII. The Nose. 

1. Size and Shape. — The enlargement of all the tissues of the 
nose occurring in acromegaly has already been mentioned. In 
myxcedema the nostrils are sometimes thickened and the whole nose 
loses its delicacy of shape. A red nose is popularly and correctly 
associated with alcoholism, but in many cases identical appearances 
are produced by acne rosacea or by lupus erythematosus, as well as 
by circulatory anomalies without any other disease. 

Falling in of the bridge of the nose may be due to syphilis of 
the nasal bones, especially when there are scars over the sunken 
portion, but is sometimes present without any disease. 

The small, narrow nose associated with adenoid growths has 
already been mentioned. 

2. The nostrils move visibly in many conditions involving dysp- 
noea (diseases of the heart and lungs, acute infections, etc.), and 
this is sometimes useful in suggesting to the physician the possibil- 
ity of pneumonia, hitherto unsuspected. Dried blood in the nostrils 
may be of value as evidences of recent nosebleed. 

3. Nosebleed suggests especially trauma, infectious fevers (par- 
ticularly typhoid), and hemorrhagic diseases (purpura, haemophilia, 
acute leukaemia). 

4. A nasal discharge in a young infant (" snuffles ") suggests 
hereditary syphilis. In adults the familiar " cold in the head " may 
need a bacteriological examination to exclude the possibility of 
nasal diphtheria or to confirm a diagnosis of influenza. 

5. A small, indolent, long-standing sore on the nose or near the 
corner of the eye should always suggest epithelioma and tuberculo- 
sis. Microscopic examination may be necessary to determine the 
diagnosis. 

6. The consideration of local disease within the nose does not fall 
within the scope of this book, but is suggested by local pain, diffi- 
culty inbreathing through the nose, frequent "colds," and asthma. 

(For the examination of the ears, see below, p. 503.) 
2 



18 PHYSICAL DIAGNOSIS. 



IX. The Lips. 

1. Pallor of the mucous membrane of the lips suggests, though 
it never proves, anaemia. No diagnosis of anaemia should be made 
without at least testing the haemoglobin (Tallqvist's scale). One 
minute suffices. 

2. Cyanosis, a purplish or slatey-blue color of the lips, occurs 
in some healthy persons from simple "weathering." When well 
marked, however, it should always suggest: — («) Heart disease 
(especially mitral or congenital lesions). — (&) Lung diseases (espe- 
cially emphysema and pneumonia). — (c) Poisoning by acetanilid or 
other coal-tar antipyretics, producing methaemoglobinaemia. 

The last is easily tested by noting the brownish (not red) tint 
of the blood when soaked into filter paper, as in performing Tall- 
qvist's haemoglobin test; the test should be confirmed by the his- 
tory. Disease of the heart or lung is identified by physical exami- 
nation of the chest. 

3. Parted lips, an open mouth, may be a mere habit or may be 
due to nasal obstruction (adenoids). Idiots and cretins are very 
apt to keep their mouths open, whether there is enlargement of the 
tongue or not. Dyspnoea may compel a patient to keep his mouth 
open so as to get more air. 

In cold weather a crack or fissure may appear, usually in the 
centre of the lower lip, and in poorly nourished individuals may 
persist for weeks. At the corners of the mouth fissures or cracks 
may be due to chapping or " cold-sores " (herpes), but if they persist 
for weeks in young children they are very suggestive of syphilis. 
White linear scars radiating from the corners of the mouth are pre- 
sumptive evidence of healed syphilitic lesions, oftenest congenital. 

4. The mucous patches of syphilis — white, sharply bounded 
areas about the size of the little-finger nail — are often seen at the 
junction of the skin with the labial mucous membrane, especially at 
the corners of the mouth. 

5. Herpes ("cold sores ") is due to a lesion of the G-asserian 
ganglion, with resulting " trophic " disturbances of the regions sup- 



THE HEAD AND FACE. 



19 




Fig. 11.— Epithelioma of the Lip. 



plied by the trigeminal nerve. Appearing first as a cluster of vesi- 
cles (" water blisters ") which break and leave a small sore near the 
mouth, herpes is to be distinguished by: (a) its distribution, near 
the terminations of some branch or branches of the trigeminal nerve 
(" herpes frontalis, nasalis, 
labialis"); (7>) by its lasting 
but a few days; and (c) by 
the absence of similar lesions 
elsewhere. It may be con- 
nected with a "cold" (which 
is often a disease of the tri- 
geminus), but it frequently 
occurs without any discov- 
erable cause. Herpetic stomatitis ("canker sores") may accom- 
pany it. 

6. Epithelioma l of the lip and chancre should be suspected when- 
ever a long-standing sore is discovered there. Epithelioma occurs 
almost always on the lower lip in a man past middle life (see Fig. 
11). It lasts longer than chancre, is slower in producing glandular 

enlargement at the angle of the jaw, 
and is not associated with other syph- 
ilitic lesions. 

7. Chancre of the lip is commoner 
in women and may occur at any age, 
especially under forty. The sore 
usually lasts but a few weeks, ex- 
cites early enlargement of the glands, 
and is usually associated with other 
manifestations of syphilis (see Fig. 
12). 

8. Angioneurotic mdema appears 
as a sudden, painless, apparently causeless swelling of the whole 

1 It does harm to call this lesion "cancer" because this term is so firmly as- 
sociated in the lay mind with metastasis, recurrence, and death that unnec- 
essary suffering may result when the patient or his family learns that he has 
" cancer. " 




Fig. 12.— Chancre of the Lip. 






20 



PHYSICAL DIAGNOSIS. 



lip (see Fig. 13), which may attain double its normal size. The 
diagnosis depends on the exclusion of all known causes (trauma, 

infection, insect bites) and on 
the history of similar swellings 
(on the lip or elsewhere) in the 
past. 

9. The enlargement of the 
lips in myxoedema and cretin- 
ism has been mentioned above 
(page 18). 

10. Hare-lip is a vertical 
slit (congenital deficiency) in 
the upper lip opposite to the 
nostril; it is often connected 
with an antero-posterior cleft 
through the hard palate ("cleft 
palate"). The lesion maybe 
double, leaving a small island 
of tissue continuous with the 
nasal septum (intermaxillary 

bone). Diagnosis is made at a glance. 




Fig. 13.— Angioneurotic CEdema of Lower Lip. 



X. The Teeth. 

The first set of teeth is fairly constant in its order and date of 
appearance. In Fig. 14 the number of the month when each tooth 
is most apt to appear is marked on the tooth. The second set (per- 
manent teeth) arrives (less regularly) between the sixth and the 
fifteenth year, except the " wisdom 
teeth," which appear about the twenty- 
first year. 

1. Rickets or cretinism often de- 
lays dentition considerably. 

2. Congenital syphilis may be as- 
sociated with deformities of the cen- 
tral incisors (permanent). The most fig. u.-Diagram showing the Month 

. . ,,, , . t,. h~ at which Each Tooth (of the First Set) 

constant is that shown in r lg. lt>. should Appear 




THE HEAD AND FACE. 



21 



3. Teeth-grinding. — Nervous, delicate, oversensitive children 
often grind their teeth in their sleep. There is no foundation for 
the popular superstition that this act indicates " worms." 








Fig. 15.— Notched Incisors in Congenital Syphilis. 

XI. The Breath. 

Foul breath is oftenest due to : 

(a) Foul teeth and gums (neglected). 

(b) Stomatitis of any variety. 

(c) Gastric fermentation (with or without constipation). 
Rarer causes are abscess or gangrene of the lung, in which the 

breath may be intensely foul; the source of the odor is made evi- 
dent by the sputa. 

Acetone breath has a faintly sweetish odor, which has been com- 
pared to that of chloroform, new-mown hay, and rotting apples. 
It occurs not only in diabetes, but in various conditions involving 
starvation (vomiting, fevers), and especially, but not only, a lack 
of carbohydrates. 1 

In uraemia a foul odor is often noticed, and an ammoniacal 
("urinous") smell has been mentioned by many writers. In ty- 
phoid and in syphilis some persons seem to detect a characteristic 
odor, but the evidence is insufficient. Alcoholic breath is often of 



1 See Taylor: "Studies on an Ash-free Diet." University of California 
Publication, July 30th, 1904. 



22 PHYSICAL DIAGNOSIS. 

value in correcting the false statements of its possessor. In coma- 
tose persons we must remember that a drink may have been taken 
just before an attack of apoplexy or any other cause for coma, so 
that an alcoholic breath in comatose patients does not prove that 
the coma is due to alcohol. 

In poisoning by illuminating gas the gaseous odor of the breath 
may be noticed. 

XII. The Toxgue. 

The act of protruding the tongue may give us valuable informa- 
tion on the condition of the nervous system. 

(a) The hesitating, tremulous tongue of typhoidal states is very 
characteristic. Simple tremor is seen in alcoholism, dementia par- 
alytica, and weakness. 

(5) If the tongue is protruded to one side, it usually means facial 
paralysis as part of a hemiplegia; rarely it is due to lesions of the 
hypoglossal nerve or its nucleus (in bulbar paralysis or tabes). 

(c) A coated tongue (due mostly to lack of saliva) is not often of 
much value in diagnosis, and there is no need to distinguish the 
varieties and colors of coats ; but a few suggestions may be obtained 
from it. Many persons who seem otherwise perfectly healthy have 
coated tongues in the early morning. This is especially true in 
mouth-breathers, in smokers, and in those who keep late hours. 

In those whose tongues are usually clean the appearance of a 
coat is associated often with gastric fermentation, constipation, or 
fevers. 

A clean tongue in a dyspeptic suggests hyperacidity or gastric 
ulcer. This point I have found of more value than any inference 
from a coated tongue. 

A dry, hr own-coated, perhaps cracked tongue goes with serious 
exhausted states and wasting diseases with or without fever. 

((/) Cyanosis and jaundice may be seen in the tongue, but bet- 
ter elsewhere. 

(e) Indentation of the edges of the tongue by the teeth occurs 
especially in foul, neglected mouths, but has no diagnostic value. 

(/) Herpes ( iC canker ") often occurs on the tongue; it begins as 



THE HEAD AND FACE. 



23 



a group of vesicles, but these rupture so soon that we usually see 
first a very small, grayish ulcer with a red areola. Jt heals in a 
clay or two, i.e., more quickly than the syphilitic mucous patch or 
any other lesion with which it is likely to be confounded. 

(g) Cancer, tuberculosis, and syphilis may attack the tongue and 
form deep, long-standing ulcerations. Syphilis can usually be diag- 
nosed by the history, the presence of other syphilitic lesions, and 
the therapeutic test (see Fig. 16). Cancer and tuberculosis should 




Fig. 10.— Syphilis of the Tongue. 



be diagnosed by microscopic examination, though cancer is more 
commonly found in men (especially smokers) past middle life and 
on the side of the tongue. 

(A) " Simple ulcers " are due to irritation from a tooth or to 
trauma, and heal readily if their cause is removed. 

(/) Fissures of the tongue are usually due to syphilis, which is 
recognized in other lesions. 

(,/) Leukoplakia buccalis (lingual corns) refers to whitish, 
smooth, hard patches of thickened epithelium, usually on the dor- 
sum of the tongue in smokers, running a chronic course without 
pain or ulceration, but important because epithelioma has been 
known (and not very rarely) to develop in them. 

(&) Geographic tongue is a desquamation of the lingual epithe- 



24 



PHYSICAL DIAGNOSIS. 



Hum in sinuous or circinate areas, which spread and fuse at their 
edges, while the central portions heal, giving a look something like 
the mountain ranges in a geographical map. It usually gives no 
trouble unless the patient's attention becomes concentrated on it. 

(V) -Hypertrophy oi the tongue has already been mentioned in 
connection with myxoedema and cretinism. It may occur independ- 
ently as a congenital affection. 

XIII. The Gums. 

(a) A lead line should be looked for in every patient as a matter 
of routine, as it may not be suggested by anything in the patient's 
symptoms or history, yet may be the key to the whole case. 

The deposit of lead sulphide in (not on) the gums is not blue, 
but gray or black; and is not a line, but a series of dots and lines 







Fig. 17.— Lead-dots in the Gums. 



arranged near the free margin of the gums and about one millimetre 
from it. Where there are no teeth there is no lead line. In faint 
or doubtful cases a hand lens is of great assistance and shows up 
the dotted arrangement of the deposit very clearly (see Fig. 17). It 
is unfortunate that the term " blue line " has become attached to 
these gray-black dots. 



THE HEAD AND FACE. 25 

(b) Sordes, a collection of epithelium, bacteria, and food parti- 
cles, accumulates about the roots of the teeth with great rapidity in 
febrile cases, but has no considerable diagnostic importance. 

(c) Sjjongy and bleeding gums occur as part of the disease 
"scurvy," after overdoses of mercury or potassic iodide, in various 
debilitated states, and sometimes without known cause. The teeth 
are loosened and the flow of saliva is usually profuse. The stench 
from such cases is often intolerable. 

(d) Suppuration about the roots of the teeth, (pyorrhea alveo- 
lar is) is common in neglected mouths, and seems in some cases to 
injure digestion, but in most cases its effects appear to be wholly 
local. 

(e) Gumboil (alveolar abscess), originating in a carious tooth, is 
easily recognized by the familiar signs of abscess associated with a 
diseased tooth and sometimes with a surprising amount of swelling 
of the face. 

(/) " Epulis " is a word applied to various soft tumors spring- 
ing from the jaw bone or occasionally from the gums themselves. 
Many of them are sarcomatous, but microscopic examination is nec- 
essary to distinguish these from fibroma, granuloma, and angioma. 

XIV. The Buccal Cavity. 
1. Eruptions. 

(«) Koplik's sp>ots in measles are of much importance. They 
appear chiefly in the inside of the cheeks, opposite the line of clos- 
ure of the molars, and consist of minute, bluish-white spots, each 
surrounded by a red areola and sometimes fusing into larger red 
areas. 

(V) The syphilitic mucous patch (see above) should be looked 
for in suspicious cases, not only in easily accessible parts of the 
mouth, but round the roots of the gums, where the cheeks or lips 
have to be pushed away to afford a good view. 



26 PHYSICAL DIAGNOSIS. 



2. Pigmentations. 

In Addison's disease brown spots or patches often occur on any 
part of the mucous membrane of the mouth. They may also occur 
in negroes without any disease and after ulcerations {e.g., from a 
tooth), so that they are not distinctive of Addison's disease. 

3. Gangrene. 

Gangrene (stomatitis gangrenosa, "noma"), a rare disease of 
weakly children, starts as a hard red spot inside the cheek and 
usually not far from the corner of the mouth. There is a swelling 
of the whole cheek, especially under the eye. The odor of gan- 
grene is usually the first thing to make clear the diagnosis. Then 
the gangrene appears externally as a black patch on the cheek, sur- 
rounded by a red halo. 

XV. The Tonsils and Pharynx. 

Method of Examination. — Place the patient facing a good 
light, natural or artificial. Ask him to open his mouth without 
protruding the tongue. Ask him to say "Ah." Then gently press 
down and forward on the dorsum of the tongue (not too far back) 
with a spoon or tongue depressor, 1 until a good view of the throat 
is obtained. 

Look especially for : 

1. Inflammations (redness, eruptions, spots, or membranes). 

2. Ulcerations. 

3. Swellings. 

4. Eeflexes. 

1. Inflammations. 

(a) General redness means a mild or early pharyngitis, but may 
precede severe diseases like diphtheria and scarlet fever. 

1 If the patient is especially nervous, it is sometimes well to let him press 
down Lis tongue witli his own forefinger. 



THE HEAD AND FACE. 



27 



(b) Yellowish-white spots on the tonsils, more or less confluent, 
mean follicular tonsillitis in the vast majority of cases, but only by 
culture can we exclude diphtheria with certainty. Fever and head- 
ache are usually present. 

(c) A membrane, continuous and grayish-white over one or both 
tonsils, especially if it extends to soft palate and uvula, means 
diphtheria in almost every case. 1 Rarely a similar membrane is 
seen in streptococcus throats with or without scarlet fever. Cult- 
ures alone can decide. 

(d) The eruptions of smallpox and chickenpox may be distributed 
in the pharynx as well as over the rest of the respiratory tract. 
They are recognized by association with more characteristic skin 
lesions and constitutional signs. 

2. Ulcerations. 

(a) Deep ulcerations of the tonsils or soft palate are oftenest 
due to syphilis. Improvement under potassium iodide and the 
manifestations of syphilis elsewhere make the diagnosis possible. 

(b) Tuberculosis may produce similar deep ulcerations, recog- 
nized by their association with obvious tuberculosis of the lung or 
larynx. Occasionally smaller "miliary" tubercles, not unlike 
"canker sores," are seen in the tonsillar region. Their chronic 
course and the presence of other tuberculous lesions identify them. 

(c) Malignant disease (oftenest sarcoma) may attack the tonsil, 
and forms a rapidly growing and finally ulcerating tumor. No 
other lesion of the tonsil grows so fast and invades surrounding 
parts so extensively except abscess; in abscess the pain, fever, and 
constitutional manifestations are far greater. 



1 Thrush, a rather rare disease of ill-nourished infants, due to a fungus of 
the yeast order, may produce on the pharynx, tongue, or in any part of the 
mouth, patches of white membrane. As the disease is almost wholly local 
and without constitutional manifestations, it is passed over briefly here. 

Streaks of mucus or bits of milk coagulum are sometimes mistaken for a 
membrane. 



28 PHYSICAL DIAGNOSIS. 



3. Swellings. 

(a) Chronic swollen tonsil (unilateral or bilateral) without fever 
or constitutional symptoms represents usually the residual hyper- 
trophy following many acute attacks of tonsillitis or may be part of 
the general adenoid hypertrophy so common in children's throats. 
Barely it forms part of the leuksemic or pseudo-leuksemic process. 

(b) Acute swollen tonsil is usually part of follicular tonsillitis (see 
above), but may occur without spots, and often accompanies scarlet 
fever. Swelling, pain in swallowing, and fever are the essentials 
of diagnosis. Our chief care should be to exclude : 

(c) Tonsillar abscess (quinsy sore throat). Here the swelling is 
usually unilateral and greater than in follicular tonsillitis. The 
pain, which is often severe, is continuous and not merely on swal- 
lowing. Fever, constitutional symptoms, and swelling of the 
glands at the angle of the jaw are all more marked than in follicu- 
lar tonsillitis. The voice is nasal or suppressed, and there is often 
salivation. The pillars of the fauces and the soft palate take part 
in the swelling and the throat may be almost blocked by it. The 
suffering increases until the abscess breaks or is opened. Fluctu- 
ation is often late and indefinite, but should always be sought for. 

(d) Retropharyngeal Abscess. — A swelling in the back of the 
pharynx near the vertebrse occurs not infrequently during the first 
year of life. A peculiar cry or cough, like the bark of a puppy or 
the call of a heron, is very often associated (the French " cri de 
canard"). The parents are often unaware that the throat is the 
seat of the trouble, and only digital examination proves the pres- 
ence of bulging and fluctuation, usually on one side of the poste- 
rior pharyngeal wall. 

A similar abscess of chronic course may complicate cervical 
caries (see below, page 31). 

(e) Swollen uvula, with transparent oedema of its tip, often com- 
plicates a pharyngitis or any lesion with violent cough. Elonga- 
tion of the uvula may bring it into contact with the tongue and by 
tickling excite cough. 



THE NECK. 



29 



(/) Perforation of the soft palate or its adhesion to the back of 
the pharynx means syphilis almost invariably, and, as it may be the 
only sign of an old infection, it is a valuable piece of evidence. 



4. Reflexes. 

(a) Lively or exaggerated pharyngeal reflexes, such that the pa- 
tient gags and coughs as soon as one touches the dorsum of the 
tongue, are seen in many nervous persons and in many alcoholics 
without nervousness. It is this condition, combined with a smok- 
er's pharyngitis, that leads to many cases of morning vomiting in 
alcoholics. 

(6) Diminished or absent reflexes (with paralysis of the palate) 
occur in postdiphtheritic neuritis and bulbar paralysis. Fluids are re- 
gurgitated through the nose and the voice has a peculiar intonation. 

To test for paralysis, ask the patient to say "Ah." In unilat- 
eral paralysis one side of the palate remains motionless ; in bilate- 
ral paralysis the whole palate is still. 

THE NECK. 

Long, thin necks are often seen in phthisical individuals, and 
short necks in the emphysematous, but nothing more than a bare 
hint can be derived from such facts. The lesions oftenest searched 
for in the neck are : 1. Enlarged glands (cervical adenitis). 2. Ab- 
scesses and scars. 3. Thyroid tumors. 4. Pulsations (see below, 
page 88). 5. Torticollis and other lesions simulating it. 6. Tu- 
berculosis of the cervical vertebrae. 

Barer lesions will be mentioned below. 



I. Chains of Enlarged Glands 

radiate in all directions from the angle of the jaw — upward, in 
front of the ear and behind it, forward along the ramus of the jaw, 
and downward to the clavicle. The areas drained by the different 
groups overlap so much that it is not necessary to distinguish them. 



30 PHYSICAL DIAGNOSIS. 

The commonest causes of enlargement are : 

(a) Tonsillitis and other inflammations within or around the 
mouth (diphtheria, the exanthemata, "cankers," carious teeth, 
etc.). Glandular swellings due to these causes are usually acute 
and more or less tender ; most of them disappear in a fortnight or 
less, but some persist (without pain) indefinitely. 

(b) Tuberculosis; long-standing cervical adenitis in children 
and young adults, with a tendency to involve the skin and to suppu- 
rate, is usually due to this cause. Certain diagnosis depends on 
microscopic examination, animal inoculation, and the tuberculin 
test. 

(c) Syphilis; small, non-suppurating glands, occurring in the 
neck and about the occiput in adults, often accompany syphilis, but 
the diagnosis depends on the presence of unmistakable syphilitic 
lesions elsewhere. 

(d) Hodgkin's disease; chronic, large, rarely suppurating glands 
in the neck, axillae, and groins, with slight splenic enlargement and 
normal blood, suggest Hodgkin's disease, but microscopic examina- 
tion is necessary to exclude tuberculosis. A superficial gland can 
be excised under cocaine, with very little pain. 

(e) Lymphatic Leukaemia. No distinguishing characteristics 
can be found in the glands, but any nodular enlargement in the 
neck should lead us to examine a film specimen of blood, and the 
leuksernie blood changes are easily and quickly recognized. 

(/) Malignant disease (near by or at a distance) may enlarge 
the cervical glands. Cancer of the lip or tongue, sarcoma of the 
tonsil, and, among distant lesions, cancer of the stomach and sar- 
coma of the lung have caused enlargement of these glands in cases 
under my observation. 

(g) If the parotid gland alone is swollen and there are fever and 
pain on chewing, the case is probably one of mumps, especially if 
there are other cases in the vicinity. Malignant disease may also 
attack the parotid. 

(Ji) German measles may be accompanied by swelling of the pos- 
terior cervical or occipital glands without the involvement of any 
other. 



THE NECK. 



31 



II. Abscess or Scars. 

Abscess or scars in the sides and front of the neck generally re- 
sult from glandular tuberculosis ; hence the presence of scars may 
be of value in the diagnosis of doubtful cases with a suspicion of 
tuberculosis in later life. Aside 
from glandular abscesses (tuber- 
culous or septic) it is rare to find 
any suppuration in the neck, ex- 
cept in the nape, where deep, 
septic abscess (carbuncle) and 
superficial boils are common. 
High Pott' s disease may be com- 
plicated by abscess (see Fig. 18). 

III. Thyroid Tumors 

occur chiefly in two diseases : 

(a) Simple goitre (unilateral 
or bilateral). 

(b) Goitre with exophthalmos, 
tachycardia, and tremor (Graves' 
disease). 

The tumor itself is identical 
in both these diseases (see Fig. 
19) ; it varies in outline and Fl(J 18> _ Cervical Abscess in Pott's Disease. 
Consistency according to the (Bradford and Lovett.) 

amount of gland tissue and 

fibrous or cystic degeneration that is present. Owing to its con- 
nection with the larynx it moves up and down somewhat when the 
patient swallows, but is not attached to any other structures in 
the neck. The enlargement is often unilateral or largely so. If 
very vascular, the tumor may vary greatly in size from moment to 
moment or at certain times (i.e., menstruation, pregnancy). 

Since the normal thyroid can rarely be felt, atrophy of the gland 
(as in myxoedema) is unrecognizable. 




32 



PHYSICAL DIAGNOSIS. 



Cancer or sarcoma have occurred in the thyroid and may be diffi- 
cult to distinguish from goitre. Malignant tumors are usually 

painful, grow fast, are ac- 
companied by 




and anaemia, 



emaciation 
are often 



Fig. 19.— Simple Goitre. 

due to irritation of the spinal 
abscess, scar, or tumor, but 
more often occurs without 
known cause ("rheumatic" 
and "nervous" cases). The 
muscle is rigid and tender. 

(Z>) Congenital torticollis (a 
counterpart of club-foot) is 
due to shortness of the muscle 
without spasm. It is almost 
always right-sided and associ- 
ated with facial asymmetry. 

(c) Dislocation of the upper 
cervical vertebral causes a dis- 
tortion of the neck much like 
that of torticollis (see Fig. 20). 
The diagnosis depends on the 



harder and more nodulated 
than benign goitres, and 
invade the neighboring tis- 
sues and lymphatics. His- 
tological examination 
should decide in doubtful 
cases. 

IV. Torticollis ( Wry-necTc) 
and Other Lesions Re- 
sembling It. 

(a) Spasm (tonic, rarely 

clonic) of the sterno-mas- 

toid and trapezius may be 

accessory nerve by swollen glands, 




FIG. 20. 



-Dislocation of the Cervical Vertebras. 
(Walton.) 



THE NECK. &6 

history of injury, the absence of true muscular spasm, and the #-ray 
picture. 

(r/) Compensatory cervical deviations : (1) When there is marked 
lateral curvature of the spine, with or without Pottfs disease, the 
head may be inclined so far to the opposite side that torticollis is 
simulated (see below, page 71). (2) When the power of the two 
eyes is markedly different, as in some varieties of astigmatism, the 
head may be habitually canted to one side to assist vision. (3) In 
some cases due to none of the above causes, habit or occupation 
(heavy loads on one shoulder) seem to produce the condition. 

(e) Forced attitude from cerebellar disease may resemble torti- 
collis. The diagnosis depends on the other evidences of intracranial 
disease. 

V. Cervical Pott's Disease ( Vertebral Tuberculosis) 

has the characteristics alluded to below in the section on joint tu- 
berculosis, viz., stiffness due to muscular spasm, malposition of the 
bones and of the head, and abscess formation (see page 31). 

Diagnosis depends on wry-neck with stiffness of the muscles of 
the back and neck and pain in the occiput — a very characteristic 
symptom-group. The chin is often supported by the hand. 
" Rheumatic " or traumatic torticollis, however, may present all 
these symptoms, and diagnosis may be impossible without the aid 
of time and therapeutic tests. 

VI. Branchial Cysts and Fistulce. 

These, due to persistence of parts of the foetal branchial clefts, 
are not very uncommon (see Fig. 21). 

A branchial cyst is a globular or ovoid fluctuating sac, hanging 
or projecting from the side of the neck or the region of the hyoid 
bone, painless and slow of growth. It may transmit the motions 
of the carotids and be mistaken for aneurism, but has no expansile 
pulsation and occurs in youth, when aneurism is practically un- 
known. Some such cysts may be emptied by external pressure. 1 

1 A patient of mine can produce a gush of foul fluid in the mouth by 
pressure over a small cyst in the neck. 
3 



34 



PHYSICAL DIAGNOSIS. 



Branchial cysts may contain serous, mucous, or sero-sanguineous 
fluid, or hair and sebaceous material, according as their lining wall 
is derived from ectoderm or entoderm. Diagnosis depends on the 
position and consistency of the growth and on the results of as- 
piration. 

Branchial fistulce (congenital) may open externally in the neck, 

and occasionally are com- 
plete from neck to phar- 
ynx. They may become 
occluded and suppuration 
result. 

VII. Actinomycosis. 

Actinomycosis, though 
it usually arises in the 
lower jaw bone, may ap- 
pear externally in the 
neck. A dense infiltra- 
tion with bluish-colored, 
semifluctuating areas in 
it, but without any distinct lumps or sharp outlines, is strongly 
suggestive of actinomycosis, and should always lead to a micro- 
scopic examination of excised portions or of the discharge. 

Fistulse may form, but are less common than in tuberculosis, 




FIG. 21.— Branchial Cyst. 



VIII. A Cervical Bib, 

springing from the seventh cervical vertebra and ending free or at- 
tached to the first thoracic rib, appears in the neck as an angular 
fulness which pulsates, owing to the presence of the subclavian ar- 
tery on top of it. It rarely produces any symptoms and is gener- 
ally encountered when percussing the apex of the lung. The bone 
can be felt behind the artery by careful palpation and demonstrated 
by radiography. 



CHAPTER III. 
THE ARMS AND HANDS; THE BACK. 

THE AKMS. 

Most of the lesions of these parts are joint lesions and. are dealt 
with in the section on joints. Others fall under the province of the 
neurologist or the dermatologist, but must be briefly mentioned here. 

I. Paralysis of One Arm. 

Paralysis of most or all the muscles of one arm occurs oftenest 
in: (a) Hemiplegia — -with paralysis of the leg and often of the face 
on the same side, (b) Pressure neuritis — traumatic or from new 
growths, (c) Obstetrical paralysis — neuritis from injury during par- 
turition, (d) Lead or alcoholic neuritis — extensors of wrist espe- 
cially, and often in both arms. (e) Anterior poliomyelitis — infantile 
paralysis, (f) Hysteria and traumatic neuroses. 1 

Pressure Neuritis. — The history of the case is of the greatest im- 
portance. During surgical anaesthesia the brachial plexus or the 
musculo-spiral nerve may be compressed, and paralysis is noted as 
soon as the patient comes out of anaesthesia. In a similar way in 
deep sleep, especially drunken sleep with the arm hanging over a 
bench or doubled under the body, the nerves may be injured. 
Pressure from a crutch or from the head of the humerus in fractures 
or dislocations, or even a violent fall on the shoulder without injury 
of bones, may result in a paralyzed arm. 

1 Less common are paralyses due to lesions of the arm centre in the cerebral 
cortex (tumor, softening, cyst, abscess, hemorrhage, thromboses, or embol- 
ism). 



S6 Physical diagnosis. 

Diagnosis rests on the history, and on the fact that not oniy the 
muscles of the shoulder group and the extensors of the wrist are 
affected, but also the supinator longus, while in the toxic paralyses, 
especially lead, the supinator longus is spared. To test the func- 
tion of this muscle, grasp the patient's wrist with the thumb side 
uppermost, and resist while he attempts to flex the arm at the 
elbow. If the supinator is intact it will spring into relief on the 
thumb side of the forearm; 

Obstetrical Neuritis. — In instrumental deliveries or when forci- 
ble traction on the child's arm has been necessary, with or without 
fractures, a paralysis of the arm often results, and, what is impor- 
tant, is often not noticed till some years later, and then thought to 
have just arisen; thus it may be mistaken for anterior poliomyelitis 
or other lesions. 

Toxic Neuritis. — Lead or alcohol produces usually a weakness of 
both forearms, especially the extensors of the wrist (" wrist-drop "), 
but one side may be predominantly affected and other muscles are 
involved in most severe cases. The history, the other signs of lead 
poisoning, and the soundness of the supinator longus distinguish it 
from other paralyses. 

All these forms of neuritis are apt to be accompanied by pain, 
anaesthesia, or paresthesia, which helps to distinguish them from 
the cerebral and spinal paralyses next described. 

Acute Anterior Poliomyelitis. — Paralysis attacks a child suddenly 
and without apparent cause, perhaps after "a feverish turn." 
Either the upper arm group (deltoid, biceps, brachialis anticus, and 
supinator longus) or the lower arm group (flexors and extensors of 
wrist and fingers) may be affected. The arm is flabby and painless, 
the muscles waste rapidly, and the electrical reactions show degen- 
eration, often within a week. 

Hysterical and Traumatic Neuroses. — The history and mode of 
onset, the frequent association of sensory symptoms which do 
not fit the distribution of any peripheral nerve, spinal segment, 
or cortical area, the normal reflexes and electrical reactions dis- 
tinguish most cases of this type, but diagnosis is sometimes impos- 
sible. 



THE ARMS. 37 

Paralysis of both arms is much less common than paralysis of 
one arm, and occurs chiefly in poisoning by lead and in multiple 
neuritis. Rarely it is seen in the late stages of chronic diseases of 
the spinal cord. 

11. Wasting of One Arm. 

(a) Rapid atrophy occurs in all the types of neuritis mentioned 
above, as well as in poliomyelitis and progressive muscular atrophy. 
In the latter it occurs without complete paralysis, though the 
wasted muscles are, of course, weak. Progressive muscular atro- 
phy usually begins in the muscles at the base of the thumb and be- 
tween it and the index finger. Less often the disease begins in 
the deltoid. In either case the rest of the arm muscles are later 
involved. 

In all the atrophies just mentioned a lack of the trophic or 
nourishing functions which should flow down the nerve is assumed 
to explain the wasting {"trophic atrophy"}. From this we distin- 
guish the atrophy due simply to disuse of the muscles without nerve 
lesions. 

(b) Slow atrophy of disuse occurs in the arm in hemiplegia, in- 
fantile or adult, and in other cerebral lesions involving the arm 
centre or the fibres leading down from it. 

(c) The atrophy often seen in hysterical cases is probably due to 
disuse and is similar to that occurring in an arm that has been 
splinted after fracture or dislocation. 

III. Contractures of the Arm. 

After cerebral lesions involving the arm centre, and in almost 
any spinal or peripheral nerve lesion which involves one set of mus- 
cles and spares another, the sound muscles contract (or overact) 
and permanent deformities result. In hysteria similar contractures 
occur. Contractures have in themselves little or no diagnostic 
value, but indicate a late and stubborn stage of whatever lesion is 
present. 



38 PHYSICAL DIAGNOSIS. 



I V. (Edema of the Arm. 1 

Causes. — 1. Thrombosis of axillary or brachial vein, usually 
the result of heart disease. 2. Pressure of tumors— aneurism, can- 
cer of axillary glands, Hodgkin's disease, sarcoma of lung or medi- 
astinum. 3. Nephritis, when the patient has lain long on one side. 
4. Inflammation, usually with evidence of lymphangitis spreading 
up the arm from a septic wound on the hand. 

The diagnosis of the cause of oedema is usually easy in the light 
of the facts brought out by the general physical examination (heart, 
urine, local lesions, etc.). 

[The arteries of the arm (brachial and radial) are to be investi- 
gated for changes in the vessels (see page 90) and for the evidence 
given by their pulsations as to the work of the heart (see page 103).] 

V. Tumors of the Upper Arm. 

In the upper arm we have: 1. Fatty tumors. 2. Sarcoma of 
the humerus. 3. Kuptured biceps. 4. Syphilitic nodes on the 
humerus. 5. Tuberculosis of the humerus. 0. Gouty deposits in 
the triceps tendon. 

Fatty tumors are recognized by the history of long duration and 
very slow growth, by their superficial position, usually external to 
the muscles, and soft, lobulated feel. 

Sarcoma forms the only large tumor springing from the hu- 
merus. It is usually hard and obviously deep seated (see Fig. 22). 

Ruptured bleeps. The lower half of the biceps projects sharply 
when the muscle is contracted, looking as if the biceps had slid 
plown from its normal site. This appearance suddenly following a 
wrench or strain of the biceps is diagnostic. 

Syphilitic nodes are flattened elevations on the bone, usually 
about the size of a half-dollar, and feel like the callus after a fract- 
ure, but project only from one side of the bone. There are pain, 

1 Distinguished, like all oedema, by the fact that a dent made by pressing 
^vjth the finger does not at once disappear when the pressure is removed. 



THE ARMS. 



39 



especially at night, and moderate tenderness. A history or other 
and more characteristic lesion of syphilis is necessary for diag- 
nosis. 

Tuberculous lesions 1 are much more common on the forearm 




Fig. 22.— Sarcoma of Humerus. 



bones, but are occasionally seen on the humerus near the epiphyseal 
ends. They usually involve and perforate the skin, leaving an in- 
dolent, suppurating sinus leading to necrosed bone. The evidence 



1 A rare disease clinically identical with tuberculosis, but due to a wholly 
different organism, an animal parasite resembling a coccidium, has been de- 
scribed by Rixford, Gilchrist, Montgomery, and other Californian physicians. 



40 



PHYSICAL DIAGNOSIS. 



of tuberculosis in other organs and the slow, " cold " progress of the 
lesion assist the diagnosis. 

Gouty tophi are sometimes seen along the fasciae covering the 
triceps tendon. They are hard and painless. The diagnosis de- 
pends upon the peculiar situation of the lesions and their association 
with other evidences of gout. 



VI. Miscellaneous Lesions of the Forearm. 

Bowing of the forearm bones occurs in rickets and in Paget' s dis- 
ease (see Fig. 204). The lesions in the other parts of the body make 

the diagnosis clear. 

Local lesions of the bones of the 
forearm are chiefly tuberculosis and 
syphilis, both of which have been suf- 
ficiently described in the last section. 
In the wrist bones we find : 

1. Rachitic enlargement of the epi- 
physes. In rickets the terminal epi- 
physes at the wrists take part in the 
general epiphyseal enlargement so com- 
mon in the disease. The diagnosis is 
easy, for there is no other disease of 
infancy producing general enlargement 
of the epiphyses (see Fig. 23). 

2. Hypertrophic pulmonary osteo- 
arthropathy (Figs. 24, 25, and 26). An 
enlargement of the lower ends of the 
radius and ulna, with clubbing of the 
fingers (see below, page 47), is recog- 
nized by its association with pulmonary 

or pleural diseases of many years' duration (chronic bronchitis, em- 
pyema). 

3. Acromegalia (see page 9) affects chiefly the bones and soft 
tissues of the hand. 

4. Hypertrophic, atrophic, or tuberculous disease of the wrist- 




Fig. 23.— Rachitic Epiphysitis. 



THE HANDS. 



41 



joint will be described below (see Examination of the joints 
page 486). 

5. " Weeping sinew " or " ganglion : 
tuating, spindle-shaped swelling alon 



(tenosynovitis) forms a flue- 
one of the tendons of the 




Fig. 24.— Hypertrophic Pulmonary Osteo-arthropathy. (Thayer.) 

wrist, slow and almost painless in its course. It may be tubercu- 
lous, in which case the sac is generally divided into several parts 
("compound ganglion ") ; bacilli may occasionally be demonstrated 
in the exudate. 

. THE HANDS. 

I. Evidence of Occupation. — The horny, stiffened hands of 
the "son of toil," the stains of paint in house painters, the flat- 
tened, calloused finger-tips of the violinist, the worn fingers of the 



42 



PHYSICAL DIAGNOSIS. 



sewing woman, afford us items of information which are sometimes 
useful and worth a rapid glance in routine examination. 

II. Temperature and Moisture. — (a) The cold, moist hand 
is most commonly felt in " nervous " people under forty. It is 

almost never seen in heart dis- 
ease, which its possessor often 
fears, and does not mean 
"poor circulation," but vaso- 
motor disturbances of neuro- 
tic origin. 

(b) Cold, dry extremities — 
hands, feet, nose, ears — may 
mean simply fatigue, expos- 
ure to low temperature, or 
insufficient exercise; but in 
the course of chronic disease 
they usually mean weakness 
of the heart, and hence are 
serious. 

(c) Warm, moist hands 
are felt in Graves' disease (ex- 
ophthalmic goitre), and if the 
warmth and moisture are 
present most of the time and 
not only as a temporary phase 
■ — e.g., after violent exercise 
— this disease is strongly sug- 
gested, and a search for trem- 
or, rapid heart, goitre, and 
bulging eyes should be made. 

III. Movements of the 

Hands. — (a) The manner of 

shaking hands gives us vague 

but useful impressions of the 

patient's temperament. The nervous, cramped, half-opened hand, 

which never really grasps and gets away as soon as possible; the 




Fig. 25.— Radiographs of the Hand and Arm of 
a Case of Hypertrophic Pulmonary Osteo- 
arthropathy (the left figure) compared with 
the hand and arm of a normal individual of 
the same height (the right figure). Note espe- 
cially the thickening of the radius and ulna. 
(Thayer.) 



THE HANDS. 



43 



firm, hearty grasp ; the limp, " wilted " hand — furnish hints of 
character that every physician must take account of. 

In fevers or toxsemic states (typhoid, alcoholism) there are two 
sets of movements which recur so often that names have been given 
them, viz. : 1. Carphologia — picking and fumbling at the bed 




Fig. 26.— Radiograph of the Wrists in Hypertrophic Pulmonary Osteo-arthropathy. 

sen's Atlas.) 



(v. Ziems- 



clothes. 2. Subsultus tendinum — involuntary twitching and jerking 
of the tendons in the wrist and on the back of the hand, usually 
associated with tremor and carphologia. 

(b) Tremor of the Hands. — To test for ordinary tremor, we ask 
the patient to extend and separate his fingers widely. The motions 
are then apparent. 

Causes: 1. Nervousness, cold, or old age. 2. Fever and tox- 



44 PHYSICAL DIAGNOSIS. 

semia. 3. Alcohol (less often lead, tobacco, morphine, or other 
drugs). 4. Graves' disease. 5. Paralysis agitans. 6. Multiple 
sclerosis. 7. Hysteria. 

Most of these tremors need no comment. The intention tremor 
of multiple sclerosis (sometimes seen also in hysteria) is exagger- 
ated into coarse shaking movements when the patient tries to pick 
up a pin, drink a glass of water, or do any other act calling for the 
volitional coordination of the small hand muscles. In the presence 
of such a tremor we should look for nystagmus (see above, page 16), 
a spastic gait (see page 506), and a slow, staccato speech. This 
group of symptoms suggests multiple (or insular) sclerosis. 

In direct contrast with this is the pill-rolling tremor of paralysis 
agitans, which usually ceases during voluntary movements. The 
thumb and forefinger are near or touch one another, and move as 
if they were rolling a bread-pill. This tremor is usually associated 
with an immovable, expressionless face, a stiffened neck and back, 
and a peculiar attitude and gait (see below, page 507). 

The other varieties of tremor can usually be recognized by the 
history and associated symptoms. 

(c) Spasms or coarse tivitchings of the hand due to: 

1. Jacksonian epilepsy — convulsive attacks which begin in and 
may remain confined to one set of muscles, often preceded by prick- 
ling or other paraesthesia of the part affected, but without loss of con- 
sciousness. These muscle spasms are due usually to an irritation of 
the corresponding motor area in the cortex cerebri (tumor, soften- 
ing, chronic meningitis, etc.), but may also occur in ursemia and 
dementia paralytica. Coma and general spasms may follow. 

2. Professional Spasm. — Writers, violin-players, and others 
who use one set of muscles continually are often attacked with 
painful cramps in the muscles used (" writer's cramp "). Weakness 
or semi-paralysis of the muscles may follow. 

3. Chorea and Choreiform Movements. — True, acute chorea 
(Sydenham's) occurs in children between five and fifteen, generally 
in those who have joint troubles or heart disease, and ends in eight 
or ten weeks. The hands are usually affected first, and their 
movements are like those of restlessness and are quasi-purposive, 



THE HANDS. 



45 



i.e., movements that might have been made intentionally, though 
they are not. At first sight one would surely think the child was 
simply fidgety. 

Similar movements occur in pregnant women or sometimes after 
parturition, but the _ 




n 



type is much severer 
and is apt to be asso- 
ciated with maniacal 
symptoms. 

Post-hemiplegic 
choreaveievs to similar 
movements in the 
paralyzed hands of 
hemiplegic cases (chil- 
dren or adults). 

In hysteria or by a 
sort of psychic con- 
tagion similar move- 
ments are sometimes 
taken up in schools 
and institutions, and 
last till their cause 
is understood and re- 
moved. 

Chronic choreiform 
movements occur also 
in the rarer congeni- 
tal forms of paral- 
ysis with or without 
idiocy. 

4. Athetosis (see 
Fig. 27) means slow 
twisting and bending 
movements of the 

fingers, quite involuntary and always secondary to organic cerebral 
lesions (hemiplegia, infantile cerebral paralysis). 




4 



Fig. 



Athetosis 



Successive positions of the hands. 
(Curschmann.) 



46 



PHYSICAL DIAGNOSIS. 



5. Tetany (see Fig. 28) — a peculiar spasm of the hands (often 
of the feet as well), occurring in the course of diseases of the 

stomach and intestine in chil- 
dren, 






in nursing women, 
after gastric lavage, and after 
thyroidectomy, usually last- 
ing minutes or hours — rarely 

days. 

IV. Deformities of the 
Hands. 

1. "Claw hand" results 
from paralysis of the inter- 
ossei and lumbricales with 
contractures, and occurs when 
the median or ulnar nerves are 
paralyzed and in progressive 
muscular atrophy, syringo- 
myelia, and chronic polio- 
myelitis. 

2. "Flipper hand" (see 
Fig. 29), a common result of 
the contractures in late cases 
of atrophic arthritis. Other 
deformities of the fingers are 
common in this disease and 
in gout (see below, page 503). 

3. "Hemiplegia hand" a 
result of the contractures following hemiplegia from any cause. 

4. Myxmdema results in thickening and coarsening of the tis- 
sues of the hand ("spade hand") without bony enlargement; but 
the spade hand is a fairly common type without myxoedema, and 
one needs to see it rapidly develop in connection with other myxe- 
dematous lesions before it can have diagnostic significance. (The 
same is true of the myxedematous face.) (See Fig. 30.) 




Fig. 28.— Tetany. (Masland.) 



THE HANDS. 



47 



5. Acromegalia produces general enlargement of the bones and 
other tissues of the hands and feet. 

6. Pulmonary Osteo- arthropathy* — Any long-standing disease 
of the heart, lungs, or pleura may be followed by this peculiar hy- 
pertrophic change in all the tissues of the extremities. Mild forms 
produce " clubbed fingers," a bulbous enlargement of the finger-tips 
with double curvation of the nails, lateral and antero-posterior (see 




Fig. 29.— Atrophic Arthritis with " Flipper Hand. 1 ' 



Fig. 31). In severer forms the bones of the hand and wrist are also 
considerably enlarged (see Figs. 25 and 26). 

7. Heberden's nodes, later described under the head of hyper- 
trophic arthritis, are here pictured (Fig. 32). The distinction 
from gout has already been referred to (page 503). 

8. Atrophic arthritis (Fig. 29) (further described on page 496) 
presents its most typical lesions in the hands and wrists. The con- 
striction line opposite the articulation is observed in late cases, but 
ordinarily multiple spindle-joints symmetrically arranged are all 



48 



PHYSICAL DIAGNOSIS. 



that we see. The boggy feel, the trophic disturbances, and the 
chronic course are diagnostic. 

9. Syphilitic and tuberculous dactylitis (see Fig. 33), seen as a 



,.,,;: 




Fig. 30.— Spade Hand in Myxoedema. 



rule in young children, are not distinguished from each other by 
the physical signs. Diagnosis rests upon the history, the course, 



THE HANDS. 



49 



the results of giving tuberculin or potassic iodide, and the evidence 
of syphilitic or tuberculous lesions elsewhere. In either disease we 
have a chronic, almost painless, boggy, red enlargement of. one 
phalanx, or more, due to an indolent inflammation which starts 
from the bone or periosteum and usually burrows to the surface, to 
produce a chronic discharging sinus or ulcer. 

10. Raynaud' 's disease attacks the fingers more often than any 
other part. Osier distinguishes three grades of intensity : A. Local 




Fig. 31.— Clubbed Fingers. 



syncope (" dead fingers) following exposures to slight cold or emo- 
tional strain. The fingers become white and cold. The condition 
usually passes off in an hour or two. From similar causes we may 
have: B. Local asphyxia ("chilblains"), producing congestion and 
swelling with or without pain and stiffness and with heat or coldness 
of the part. C. Local or symmetrical gangrene. If local asphyxia 
persists, gangrene results. 



50 PHYSICAL DIAGNOSIS. 

11. Morvan's Disease. — As a part of syringomyelia multiple 
arthropathies (atrophic arthritis) and painless felons may develop 




Fig. 32.— Heberden's Nodes. 



in the hands (see Fig. 34). The appearances may strongly suggest: 
12. Leijrosy, in which there is likewise anaesthetic necrosis of 




Fig. 33.— Tuberculous Dactylitis. 



THE HANDS. 



51 



phalanges, but the two diseases can usually be distinguished by a 
study of the lesions and symptoms in other parts of the body. 

13. Dupuytren's contraction of the palmar fascia is commonest 



1 





Fig. 34.— Morvan's Disease. 



in adult men, and gradually produces a permanent, painless flexion 
of the little finger in one or both hands. A tense band is felt 
in the palm. The ring finger may also be affected; less often 



52 



PHYSICAL DIAGNOSIS. 



the others. If burn and felon are excluded, the diagnosis is 
obvious. 

The Nails. 

1. The nutrition of the nails suffers notably in many chronic 
skin diseases, in myxcedema, and in many nerve lesions (neur- 
itis, hemiplegia, syringomyelia, 
etc.). 

2. A transverse ridge and 
groove on the nails often form 
when their growth is resumed 
after an acute illness. The 
movement of this ridge from the 
matrix to the free edge is said to 
take about six months (see Fig. 
35). 

3. Hang-nails possess a cer- 
tain medical interest, because 
in some individuals they become 
sore when the general condition 
is below par, and constitute a 
rough index of the degree of re- 
sistance to infection. They may 

become infected and lead on to suppuration (paronychia). 

4. Indolent sores around the nail should rouse the suspicion of 
tuberculosis or syphilis, especially in a child. 

5. (a) Cyanosis, the slatey or purplish-blue color of venous con- 
gestion, can be well seen in the nails, (b) Anosmia, if well 
marked, blanches the tint of the tissues seen through the nail, but 
the diagnosis should invariably be confirmed by a haemoglobin esti- 
mate. 

6. Incurvation of the nails has already been referred to as a part 
of the condition known as "clubbed fingers " (page 47). 

7. Capillary pulse (see below, page 91). 




Fig. 35.— Grooved Nails after Acute Illness. 



THE BACK. 53 



THE BACK. 

The evidences of spinal tuberculosis, spinal curvature, and of 
the spinal form of hypertrophic arthritis will be described later 
(pages 489 and 502). 

1. Stiff Back. 

" Stiff back " may be due not only to the joint troubles just 
mentioned, but also and more commonly to lumbago, a painful 
affection of the lumbar muscles without known pathologic basis. 
Clinically it is characterized by pain when the muscles are used, as 
in bending forward to tie one's shoes and in recovering the upright 
position. There is no bony soreness, and sideways bending is usu- 
ally freer than in hypertrophic arthritis. The pain of lumbago 
does not radiate around the chest or down the legs, and is not espe- 
cially aggravated by coughing or sneezing, but it sometimes extends 
down low into the fascia of the lumbar muscles over the sacrum. 
The age of the patient (usually over thirty) distinguishes most cases 
of lumbago from spinal tuberculosis. 

11. Sacro-iliac Disease. 

Tuberculosis of this joint has long been known and calls atten- 
tion to its presence by pain, psoas spasm, and a limp. If the wings 
of the ilium are forcibly pressed together, the pain in the joint is 
much increased. Abscess formation is often the first distinctive 
sign. The motions at the hip-joint are not restricted and the local 
signs of vertebral caries are absent. The duration of the disease 
and the formation of abscess distinguish it from other lesions of the 
sacro-iliac joint. 

Goldthwaite x has recently shown that the sacro-iliac joint is 
subject to most of the diseases of other joints, and that some {e.g., 
hypertrophic arthritis) are not at all uncommon there. Many of 
the pains in the back complained of by women during menstruation 

1 Goldthwaite: Boston Medical and Surgical Journal, March 9th, 1905. 



54 



PHYSICAL DIAGNOSIS. 



or in pelvic disorders are referred precisely to the sacro-iliac articu- 
lation and are probably due to lesions of that joint. Many cases 
diagnosed as " lumbago " are probably due to one or another sacro- 
iliac lesion. The subject is a new but very fruitful one. 

III. Spinal Curvatures. 

Diagnosis is not difficult, provided we are led to examine the 
back at all. 

(a) Kyjjhosis or backward convexity of the spine, if sharply an- 
gular, means Pott's disease (tuberculosis). If the curve is gentle 
and gradual it maybe due to "round shoulders ," to hypertrophic 
arthritis, to emphysema, Paget' s disease, or rickets. The rachitic 
curve is flaccid, is due simply to muscular weakness, and is asso- 
ciated with other evidences of rickets. In emphysema and Paget' s 
disease the kyphosis goes with the other signs of those diseases. 
In hypertrophic arthritis the curve is rigid, irreducible, and usually 
painless. " Round shoulders " can be straightened by muscular 
exertion, and represent a habit of posture. 

(b) Lordosis, an exaggeration of the normal forward convexity 
of the lumbar spine, is seen in tuberculosis of the hip or spine, in 
paralysis of the dorsal or abdominal muscles (especially muscular 
dystrophy) , and in abdominal tumors (pregnancy) , which need to 
be counterbalanced by backward bending. 

(c) Scoliosis is a combination of lateral curvature with twisting 
of the spine. In slight or doubtful cases the tips of the spinous 
processes should be marked with a colored pencil, which makes the 
deviation easily visible. Severe cases cannot be mistaken. 

IV. Tumors of the Bach. 



(a) Aneurism of the descending aorta may point in the back 
near the angle of the left scapula (see below, page 289). It is the 
only pulsating tumor of this region. 

(b) Perinejjhritic abscess usually points between the crest of the 
ilium and the twelfth rib, a few inches from the spine (see page 416). 



THE BACK. 55 

(c) Tuberculous abscess (" cold abscess"), originating in verte- 
bral tuberculosis, may point in the same region, though more often 
it follows down the sheath of the psoas and points near Poupart's 
ligament. "Cold abscess," starting from a necrosed rib, is often 
seen in the back. The probe leads to dead bone at the end of the 
sinus. Microscopic examination of excised pieces is the only way 
of excluding actinomycosis, though this disease is less apt to form 
sinuses. 

(d) Sarcoma of the scapula, the only tumor of the scapula that 
is often seen, occurs in children and rarely after the second decade. 
With a solid, nearly painless tumor of this bone in a child, sarcoma 
should always be suspected. Benign exostoses are possible, but 
usually occur later in life. Histological examination will decide. 

(e) Epithelioma, arising from the skin of the back, presents the 
ordinary evidences of this form of cancer. 

V. Prominent Scapula. 

This is due usually to : 

(«.) Lateral curvature of the spine (see above). 

(b) Serratus paralysis, recognized by the startling prominence 
of the scapula if the patient pushes forward with both hands against 
resistance ("angel-wing" scapula). 

VI. Spina Bifida. 

A congenital, saccular tumor, connecting through a bony defect 
with the interior of the spinal canal at any point between the occi- 
put and the sacrum ; nine-tenths of all cases occur in the lowest 
third of the spinal column. There is no other congenital tumor in 
this position communicating with the spinal canal. 

In the sacral region there are other congenital tumors, dermoid 
cysts, lipomata, and others. Their nature can be learned only by 
incision, but they are all distinguished from spina bifida by the lack 
of communication with the spinal canal. 



THE CHEST. 

INTRODUCTION. 

I. Methods of Examining the Thoracic Organs. 

To carry out a thorough examination of the chest we do five 
things: 1. We look at it; technically called "inspection." 2. We 
feel of it; technically called "palpation." 3. We listen to the 
sounds produced by striking it; technical^ called "percussion." 
4. We listen to the sounds produced within it by physiological or 
pathological processes; technically called "auscultation." 5. We 
study pictures thrown on the fluoroscopic screen or on a photo- 
graphic plate by the Roentgen rays as they traverse the chest ; 
technically called "radioscopy." 

Measuring the dimensions or the movements of the chest ("men- 
suration") is often mentioned as co-ordinate with the above meth- 
ods, but it yields very little information of practical value, and is 
at present very little used. 

Without some knowledge of the regional anatomy of the chest 
no intelligent investigation of the condition of the thoracic organs 
can be carried on. Accordingly, I shall begin by recalling very 
briefly some of the most essential anatomical relations. 

II. Regional Anatomy of the Chest. 



It seems to me a mistake to divide the chest into arbitrary por- 
tions and to describe physical signs with reference to such division. 



INTRODUCTION. 



57 



The seat of any lesion can best be described by giving its relation 
to the clavicle, sternum, or ribs on the front and sides of the chest, 
and to the scapulae and ribs behind. Thus we may speak of rales 
as heard "above the left clavicle in front," "below the right scap- 
ula behind," "between the seventh and ninth ribs in the axilla," 
and so on. When we want to state more exactly what part of the 
axilla anteroposterior^ is affected, we may refer to the " mid-axil- 
ary line " (see Fig. 36) ; or better, we may place the lesion by meas- 
uring the number of centimetres or inches from the median line of 
the sternum. In a similar way the place of 
the apex impulse of the heart (whether in 
the normal situation or farther toward the 
axilla) can be determined by measuring from 
the median line of the sternum. Measure- 
ments referring to the nipple are entirely 
useless in women and not very reliable in 
men. It is better to measure as above. 

If, then, we confine ourselves chiefly to 
the bones of the chest as landmarks, and 
fix, with reference to them, the position of 
any portion of the internal organs which we 
desire to study, it becomes unnecessary to 
memorize any technical terms or to learn 
the position of any arbitrary lines and divi- 
sions such as are frequently forced upon the 
student. The only points which it is neces- 
sary to memorize once for all are : 

1. The position of the heart, lungs, liver, 
and spleen with reference to the bones of the 
chest. 

2. The position of certain points which 
experience has taught us have a certain 
value in physical diagnosis. I mean (a) the 
so-called " valve areas " of the heart, which 

do not correspond to the actual position of the valves, for reasons 
to be explained later on, and (b) the percussion outlines of the 




Fig. 36. 



The Mid-Axillary 
Line. 



58 



PHYSICAL DIAGNOSIS. 



heart, liver, and spleen. These outlines do not correspond in size 
with the actual dimensions of the organs within, yet there is a 
definite relation between the two which remains relatively constant, 
so that we can infer the size of the organ itself from the outlines 
which we determine by percussion. The position of the organs 
themselves is shown in Figs. 37, 38, and 39. It will be noticed in 



Right lung 
Right auricle. 

Liver. 




Upper lobe of left 
lung. 



Left ventricle. 



Lower lobe of left 

lung. 



Fig. 37.— Position of the Heart, Lungs, Liver, and Stomacb. The dotted lines correspond to the 
outlines of the lung; the heavy continuous line represents tbe heart; while the position of 
the liver and of the lower border of the stomach is indicated by light continuous lines. The 
ribs are numbered. 



Fig. 37 that the lungs extend up above the clavicles and overlap 
the liver and the heart — facts of considerable importance in the 
physical examination of these organs, as will be later seen. It 
is also to be noticed how small a portion of the stomach is 
directly accessible to physical examination, the larger part of it 
lying behind the ribs and covered by the liver. The normal pan- 
creas and kidneys are practically inaccessible to plrysical examina- 
tion. 

The percussion outlines — corresponding to those portions of 
the heart, liver, and spleen which lie immediately beneath the 



INTRODUCTION. 



b\) 




Upper lobe. 



„-. Lower lobe. 



Spleen. 

Lower lobe. 




Upper 
lobe. 



Kiddle 
lobe. 



Liver 



Fig. 38.— Position of -the Left Lung from the Fig. 39.— Position of the Right Lung from the 
Sides and of the Spleen. Side, and of the Liver. 



chest walls — will be illustrated in the section on Percussion (see 
page 118). 



CHAPTER IV. 
TECHNIQUE AND GENERAL DIAGNOSIS. 

INSPECTION. 

Much may be learned by a careful inspection of all parts of the 
chest, but only in case the clothes are wholly removed. A good 
light is essential, and this does not always mean a direct light ; for 
example, when examining the front of the chest it is often better 
to have the patient stand with his side to the window so that the 
light strikes obliquely across the chest, accenting every depression 
and making every pulsation a moving shadow. In searching for 
abnormal pulsations, this oblique light is especially important. 
In examining the thorax we look for the following points : 
1. The size. 

The general shape and nutrition. 

Local deformities or tumors. 

The respiratory movements of the chest walls. 

The respiratory movements of the diaphragm. 

The normal cardiac movements. 

7. Abnormal pulsations (arterial, venous, or capillary). 

8. The peripheral vessels. 

9. The color and condition of the skin and mucous membranes. 

10. The presence or absence of glandular enlargement. 



2. 
3. 
4. 
5. 
6. 



I. Size. 



Small chests are seen in patients who have been long in bed 
from whatever cause ; also in those who have suffered in infancy 
from rickets, adenoid growths in the naso-pharynx, or a combina- 
tion of the two diseases. Abnormally large chests are seen chiefly 
in emphysema. Of course the chests of healthy individuals vary 



INSPECTION. 



61 



a great deal in size at any given age, and I have been referring in 
the last sentences only to variations greater than those normally 
found. 

II. Shape. 

There are marked differences in shape between the child's and 
the adult's chest in health. A child's trunk, as compared with 




Fig. 40.— Funnel Breast. 



that of an adult, is far more nearly cylindrical ; that is, the antero- 
posterior diameter is nearly as great as the lateral. The adult's 
chest is distinctly flattened from before backward, although indi- 
vidual variations in this respect are considerable, as Woods Hutch- 
inson has shown. 

In childhood the commonest pathological modifications are due 



62 



PHYSICAL DIAGNOSIS. 



to adenoids or to rickets; in middle and later life to emphysema, 
phthisis, or old pleuritic disease 

(a) The Rachitic Chest 

The sternum generally projects {"pigeon breast"), but in some 
cases, especially when rickets is combined with adenoid hyper- 
trophy, there may be a depression at the root of the sternum re- 
sulting in the condition known as "funnel breast" 1 (Figs. 40 and 




Fig. 41.— Funnel Breast, 

41). The sides of the chest are compressed laterally and slope in 
to meet the sternum as the sides of a ship slope down to meet 
the keel (pectus carinatum) (Figs. 43 and 44). From the origin 
of the ensiform cartilage a depression or groove is to be seen run- 
ning downward and outward to the axilla and corresponding 
nearly to the attachment of the diaphragm. This is sometimes 
spoken of as "Harrison's groove." The lower margin of the ribs 

1 In some cases this condition appears to be congenital. 



INSPECTION. 



63 



in front often flares out, owing to the enlargement of the liver and 
spleen below and the pull of the diaphragm above. Along the line 
of the chondro-costal articulation there is to be felt, and sometimes 




Fig. 42.— Acquired Depression at the Root of the Ensiform Cartilage. The patient is a shoe- 
maker of seventy, who has all his life pressed against his breast bone the shoe on which he 
worked. 

seen, a line of eminences or swellings, to which the name of " ra- 
chitic rosary " has been given. 

(b) The "Paralytic Thorax:' 

Fig. 45 conveys a better idea of this form of chest than any 
description. The normal anteroposterior flattening is exaggerated 
so that snch persons are often spoken of as "flat-chested." The 
clavicles are very prominent, owing to falling in of the tissues 



I 



64 



PHYSICAL DIAGNOSIS. 



above and below them; the shoulders are stooping, the scapulae 
prominent, and the neck is generally long. The angle where the 
ribs meet at the ensiform cartilage, the so-called " costal angle," is in 
such cases very sharp. This type of chest has often been supposed 
to be characteristic of phthisis, but may be found in persons with 
perfectly healthy lungs. On the other hand, phthisis frequently 




Fig. 43.— Pigeon Breast. 



exists in persons with normally shaped chests or with abnormally 
deep chests (Woods Hutchinson). (See Fig. 162, page 310.) 



(c) The "Barrel Chest." 

Nothing is less like a barrel than the "barrel chest" Its most 
striking characteristic is its greatly increased anteroposterior diam- 
eter, so that it approaches the form of the infant's chest. The 
costal angle is very obtuse, the shoulders are high, and the neck 
is short. The respiratory movements of the barrel chest will be 
spoken of later (see Figs. 46 and 47). 



INSPECTION. 



65 



Nutrition of the Chest Walls. 

Emaciation is readily appreciated by inspection. The ribs are 
unusually prominent, the scapulas stand out, and the clavicles pro- 
ject. All this may be seen independently of any change in the 




Fig. 44.— Pigeon Breast. 



shape of the chest such as was described above under the title of 
Paralytic Thorax. Tuberculosis of the apices of the lungs may 
produce a marked falling in of the tissues above and below the 
clavicle independent of any emaciation of the chest itself. 
5 



66 PHYSICAL DIAGNOSIS. 



III. Deformities. 

The abnormalities just enumerated are symmetrical and affect 
the whole thorax. Under the head of Deformities, I shall consider 
chiefly such abnormalities as affect particular portions of the chest 
and not the thorax as a whole. 



(a) Spinal Curvatures and Twists. 1 

A good view of the patient's back brings out best the lesser de- 
grees of lateral curvature, which are not at all infrequent in persons 
who are not aware of them. Slight degrees of deformity are best 
seen by marking with a skin-pencil the position of the spinous proc- 
esses (see Fig. 49). The more marked cases of lateral curvature, 
which are usually accompanied by a certain amount of twisting, 
give rise to considerable displacement of the thoracic organs and 
render unreliable the usual bony landmarks, with reference to 
which we judge of the position of the intrathoracic organs. By 
such deformities the apex of the heart may be pushed up into 
the fourth space or out into the axilla, or portions of the lungs 
may be compressed and made atelectatic. The bulging on the 
convex side of the curve may simulate an aneurismal tumor. 
Pott's disease of the spine should be looked for as a part of 
the routine inspection of the chest. It is sometimes better felt 
than seen. 

(b) Flattening of One Side of the Chest. 

In chronic phthisis, cirrhosis of the lung, or long- tanding pleu- 
ritic effusion, marked falling in of one side of the chest is often to 
be seen. This may be apparent in the upper and front portion, be- 

1 See also page 54. The lesions are referred to here only in relation to 
their effects on heart and lungs. 



INSPECTION. 



67 



neath the clavicle, or in the axilla, or in both situations (see Figs. 
45 and. 51). The shrinkage of the affected side is made more obvi- 




Fig. 4-5.— The Paralytic Thorax. 

ous by contrast with the compensatory hypertrophy of the sound 
lung, which makes the sound side unusually full and prominent. 

(c) Prominence of One Side of the Chest. 

In pneumothorax or pleural effusions, and sometimes in malig- 
nant disease of the lung or pleura, there is a marked increase in the 
size of the affected side of the chest. Very rarely emphysema 



. 



68 



PHYSICAL DIAGNOSIS. 



may affect one lung predominantly. In pneumothorax or pleuritic 

effusion we usually see, in addition to the above enlargement of the 

affected side, a smoothing out of 

the intercostal depressions so that 

the surface of that side is much 

more uniform than the other side. 

Bulging of the interspaces from 

great pressure within the chest 

rarely occurs. I have never seen 

it. 

(e£) Local Prominences. 



In nearly one-quarter of all 
healthy chests that part of the 
thoracic wall which overlies the 
heart (the so-called "precordial 
region ") is abnormally promi- 
nent. The cause of this condi- 
tion is much disputed. A similar 
prominence may be brought about 
in children, whose thoracic bones 
are very flexible (and occasionally 
in older patients) , by the outward 
pressure of an enlarged heart or 
of an effusion in the pericardial 
sac. The prominences due to 
spinal curvature have been al- 
ready mentioned. Less com- 
mon causes of local prominence 
are: 

1. Aneurism of the arch of 
the aorta. 

2. Tumor of the chest wall 

(lipoma, sarcoma, gumma) or of the lung, mediastinum, or of the 
thoracic glands pressing their way outward. 



Barrel Chest in a Case of Bron- 
chial Asthma (set. 13). 



INSPECTION. 



69 



3. " Cold abscess " (tuberculosis) of a rib or of the sternum. 

4. Empyema perforating the chest wall, the so-called "empyema 
necessitatis." 

IV. The Kespiratory Movements. 



(a) Normal Respiration. 

During normal respiration, one sees the ribs move outward and 
upward with inspiration, and downward and inward with expira- 
tion. Possibly one catches some 
hint of the movements of the 
diaphragm at the epigastrium. 
In men, diaphragmatic breath- 
ing is more marked, while in 
women breathing is mostly of 
the " costal type " ; that is, is 
done by the intercostal muscles. 
In certain diseases an exaggera- 
tion of the costal or of the dia- 
phragmatic type of breathing 
may be seen. In emphysema, 
for example, and in some cases 
of asthma, the ribs move very 
little, and most of the work of 
respiration is performed by the 
diaphragm, whose pull upon the 
lower ribs can sometimes be distinctly seen during inspiration. On 
the other hand, when the movements of the diaphragm are impeded 
by the presence of fluid or a solid tumor, as in cirrhosis of the 
liver or leukaemia, the breathing has largely to be performed by the 
ribs, and becomes, as we say, costal in type (see below, p. 72). 




Fig. 47.— Barrel Chest. Chronic bronchitis 
and emphysema. 



(b) Anomalies of Expansion. 

If we watch the patient while he takes a full breath, we may 
notice certain variations from the normal type of respiratory move- 



70 



PHYSICAL DIAGNOSIS. 



ments. We may see: (1) Diminished expansion of one side (as a 
whole, or at the apex). (2) Increased expansion of one side. 

(1) If diminished expansion of one side is due to pleuritic effusion, 
pneumothorax, or solid tumor of the lung or pleura, the affected 
side is usually distended as well as immobile. "When, on the other 




Fig. 48.— Severe Lateral Curvature (Un- 
treated). 



Fig. 49. 



-Lateral Curvature Three Weeks 
After Correction. 



hand, the lung is retracted or bound down by adhesions, as in 
phthisis, old pleurisy, occlusion of the bronchus, or from the pres- 
sure of an aneurism, we have immobility combined with a retraction 
of the affected side. In tuberculous disease at the apex of the 
lungs, we may see one side or both sides fail to expand at the top. 
Restriction of the motion of one side of the chest may also be due 



INSPECTION. 



71 




pain or to pressure from below the diaphragm. An enlarged liver 
or spleen and tumors of the hepatic or splenic region may in this way 
prevent the normal expansion of one or the other side of the thorax. 

Occasionally a hemiplegia or a uni- 
lateral paralysis of the diaphragm 
results in diminished movement of 
one side of the chest. 

(2) Increased expansion of one 
side of the chest is observed princi- 
pally as a compensatory or vicarious 
overfun ctioning of that side when 
the other side of the chest is thrown 
£, I out of use by a large pleuritic effu- 

1 sion, by pneumothorax, long-stand- 
\ ing pleurisy with contraction, or 
mWtt/f- other causes. 



Fig. 50.— Lateral Curvature Before Cor 
rection. 



(c) Dyspnoea. 

This term is often used rather 
loosely to include: (1) Difficult 
breathing, whether rapid or slow. 
(2) Unusually deep breathing, 
whether difficult or not. (3) Eapid 
breathing. 

True dyspnoea or difficult breath- 
ing is almost always rapid as well, 
and does not differ at all from the 
well-known phenomenon of being " out of breath n after a hard run 
or any violent exertion. Conceive these conditions as persisting 
over hours or days, and we have the phenomenon known as dysp- 
noea. The breathing is not only thick but labored; that is, per- 
formed with difficulty, and unusual muscles, not ordinarily called 
upon for respiration, come into play and are seen working above 
the clavicle and elsewhere. More or less distress is generally ex- 
pressed in the face, and there is often a blueness of the lips or a 
dusky color throughout the face. The commonest causes of dysp- 



72 



PHYSICAL DIAGNOSIS. 



noea are the various forms of heart disease, pneumonia, large 
pleuritic effusion, emphysema, asthma, and phthisis. 

Dyspnoea may affect especially inspiration, as, for example, 
when a foreign body lodges in the larynx, or in ordinary "croup." 
In such cases we speak of "inspiratory dyspnoea," distinguishing it 
from " expiratory dyspnoea " such as occurs in asthma and emphy- 
sema. In the latter condition the breath seems to enter the chest 
readily, but the difficulty is to get it out again. Expiration is 
greatly prolonged and often noisy. 

Combined types also occur in which both respiratory acts are 
difficult, 

Abnormally deep and full respiration, without any appearance of 
difficulty in the process, is sometimes seen near the fatal termina- 
tion of cases of diabetes, 
the so - called diabetic 
dyspnoea. 

Simpjle rapidity of 
breathing should be dis- 
tinguished from dyspnoea 
of any type. In adults 
the normal rate of respi- 
ration is about 18 per 
minute. In children, it is 
considerably quicker and 
more irregular. It is not 
desirable to attempt here 
to enumerate all the 
causes which may lead to 
a quickening of the respi- 
ration. Among the com- 
moner are muscular exer- 
tion, emotional disturb- 
ance, diseases of the heart and lungs, and fluid or solid accumula- 
tions below the diaphragm, which push up that muscle and cause it 
to encroach abnormally upon the thoracic cavity. Most of the in- 
fectious fevers are also apt to be accompanied by quickened breath- 




Fig. 51.— Contraction of Left Chest. Empyema. 



INSPECTION. 



73 



ing, especially but not exclusively when the fever is associated with 
a disease of the heart, lung, pleura, or pericardium. 

Sucking-in of the interspaces in the lower axillary regions or 

below the clavicles may 
be seen in connection 
with dyspnoea when- 
ever the lungs are pre- 
vented by some cause 
from properly expand- 
ing during inspiration. 
Negative pressure i s 
thus produced within 
the chest, and the at- 
mospheric pressure 
without pushes in the 
more elastic parts of 
the thorax. This phe- 
nomenon is seen in col- 
lapse or atelectasis of 
a portion or the whole 
of a lung, such as may 
occur in obstruction at 
the glottis (in which 
case both sides are 
equally retracted) o r 
from occlusion of a 
bronchus. In the lat- 
ter event, the sucking-in of the interspaces during inspiration oc- 
curs only on the affected side. 1 

1 Slight retraction of the lower interspaces in the axilla during inspiration 
is often seen in health. In disease this phenomenon is greatly exaggerated. 




Fig. 52.— Prominence of Right Side. Pleural Effusion. 



74 PHYSICAL DIAGNOSIS. 

V. Changes in the Respiratory Ehythm. 

(a) Asthmatic Breathing. 

In asthma the normal rhythm is reversed and the expiration 
becomes longer, instead of shorter, than inspiration. Inspiration 
may be represented only by a short gasp, while expiration becomes 
a prolonged wheeze lasting several times as long as inspiration. 
Dyspnoea is usually very marked. In emphysema we get very 
much the same type of breathing so far as rhythm is concerned, 
but the dyspnoea is not usually so extreme and the auxiliary mus- 
cles of respiration are not so apt to be called into use. In many 
cases of emphysema one sees the thorax move all as one piece, " en 
cuirasse," owing to a senile fixation of the bones of the thorax from 
ossification of the cartilaginous portions. In hereditary syphilis or 
phthisis this fixation may occur in youth or early middle age. 

(b) Cheyne- Stokes Breathing. 

An anomaly of respiratory rhythm in which short, recurrent 
paroxysms of dyspnoea are preceded and followed by periods in 
which no respiration occurs (apnoea). If we represent the normal 
respiratory movement by an up-and-down line, as seen in Fig. 53, 

wwwww 

Fig. 53.— Diagram to Represent Normal Breathing-Rhythm. 

the Cheyne-Stokes type of breathing would appear as in Fig. 54. 
The period of apnoea may last from one to ten seconds ; then short, 
shallow respirations begin and increase rapidly, both in volume and 
in rate, until a maximum of marked dyspnoea is reached, when a 
diminution in the rate and depth of the act begins, and the patient 
gradually returns to the apnoeic state. The length of the whole 
paroxysm may be from 30 to 70 seconds. During the apnoeic 
period the patient is apt to drop asleep for a few seconds and the 
pupils may become contracted. When the paroxysm of dyspnoea 



INSPECTION. 



75 



is at its height, he is apt to cough and shift his position restlessly, 
or in case the whole phenomenon occurs during sleep he moves un- 
easily in his sleep at this period. Modified types of the phenome- 
non also occur, in which there is a rhythmic increase and decrease 
in the depth and rapidity of respiration but without any interven- 
ing period of apnoea. This type of breathing is most often seen in 
severe cases of cardiac, renal, or cerebral disease. It is generally 
more marked at night and may occur only at that time. In chil- 
dren it appears sometimes to be physiological during sleep. As a 



X^ll/W 




Fig. 54.— Cheyne-Stokes Respiration. 



rule, it is a sign of grave prognostic significance, but patients have 
been knoivn to recover completely after weeks or even months of 
Cheyne-Stokes breathing. 

(c) Restrained or " Catchy " Breathing. 

When the patient has a "stitch in the side," due to dry pleu- 
risy, intercostal neuralgia, or to other causes, the inspiration may 
be suddenly interrupted in the middle, owing to a seizure of pain 
which makes the patient stop breathing as quickly as he can. The 
same conditions may produce very shallow breathing as the patient 
tries to avoid the pain which a fall inspiration will cause. This 
type of restrained breathing is otten seen in pleurisy .and pneumo- 
nia, and in the latter disease expiration is often accompanied by 
a little moan or grunt of discomfort 

(d) Shallow and irregular breathing is often seen in states of pro- 
found unconsciousness from any cause, such as apoplexy or poison- 
ing. A few deep respirations may be followed by a number of 
shallow and irregular ones. When death is imminent in any dis- 
ease, the respiration may become very irregular and gasping, and 
it is apt to be accompanied by a peculiar nodding movement of the 



76 PHYSICAL DIAGNOSIS. 

head, the chin being thrown quickly upward during inspiration, and 
falling slowly during expiration. I have known but one patient to 
recover after this type of breathing had set in. 

After severe hemorrhage the breathing may be of a sighing type 
as well as very shallow. 

(e) Stridulous Breathing. 
A high-pitched, crowing or barking sound is heard during inspi- 
ration when there is obstruction of the entrance of air at or near 
the glottis. This type of breathing occurs in spasm or oedema of 
the glottis, "croup," laryngismus stridulus, and forms the "whoop " 
in the paroxysms of whooping-cough. Laryngeal or tracheal ob- 
structions due to foreign bodies, or tumors within or pressure from 
without the air-tubes, may cause a similar type of respiration. It 
is in these cases especially that we see the sucking-in of the inter- 
spaces mentioned above (see p. 73). 

VI. Diaphragmatic Movements. 

Litten's Phenomenon. 

The normal movements of the diaphragm may be rendered vis- 
ible by the following procedure, suggested by Litten in 1892: The 
patient lies upon his back with the chest bared and the feet pointed 
directly toward a window. Cross lights must be altogether ex- 
cluded by darkening any other windows which the room may con- 
tain 1 (see Fig. 55). The observer stands at the patient's side 
and asks him to take a full breath. As the ribs rise with the 
movement of inspiration, a short, narrow shadow moves down along 
the axilla from about the seventh to about the ninth or tenth rib. 
During the expiration the shadow rises again to the point from 
which it started, but is less easily seen. This phenomenon is to be 
seen on both sides of the chest and sometimes in the epigastrium. 

1 If it is inconvenient to move the patient's bed into the proper position 
with relation to the window, or if the foot-board interferes, or if the observa- 
tion has to be made after dark, a dark lantern or other strong light held at the 
foot of the bed answers very well. All other light must, of course, be ex- 
cluded. 



INSPECTION. 



77 



It is best seen iii spare, muscular young persons of either sex, and 
is never absent in health except in those who are very fat, or who 
cannot or will not breathe deeply. The latter condition occurs in 




Fig. 55.— Litten's Diaphragm Shadow. Proper position of patient and of observer. The 
shadow is best seen near L. 



hysteria and in some very stupid persons who cannot be made to 
understand what is meant by a full breath. In the observation of 
several thousand cases, I have never known it absent in health 
except under these conditions. 

In normal chests, the excursion of the shadow is about two and 
a half inches; with very forced breathing three and a half inches. 
The mechanism of this phenomenon is best understood by imagin- 
ing a coronal section of the thorax as seen from the front or back 
(see Fig. 56). At the end of expiration, the diaphragm lies 
flat against the thorax from its attachment up to about the sixth 
rib. During inspiration it "peels off" as it descends and allows 
the edge of the lung to come down into the chink between the dia- 
phragm and thorax. This "peeling off" of the diaphragm and the 
descent of the lung during inspiration give rise to the moving 
shadow above described. 

By thus observing the excursion of the diaphragm we can obtain 
a good deal of information of clinical value. 



78 



PHYSICAL DIAGNOSIS. 



In pneumonia of the lower lobe, pleuritic effusion, extensive pleu- 
ritic adhesions, or in advanced cases of emphysema, the shadow is 
absent. This is explained by the fact that in pneumonia, pleuritic 
effusion, and emphysema the diaphragm is held off from the chest 
wall so that its movements communicate no shadow. In pleuritic 
adhesions the movements of the diaphragm are prevented. In 
early phthisis I have generally found the excursion of the dia- 
phragm diminished upon the affected side, owing to a loss of 
elasticity in the affected lung and in part probably to pleuritic 
adhesions. On the other hand, fluid or solid tumors below the dia- 
phragm, unless very large, do not prevent the descent of that muscle, 
and so do not abolish the diaphragm shadow. In cases in which 
the diagnosis is in doubt between fluid in the right pleural cavity 
and an enlargement of the liver upward or a subdiaphragmatic ab- 
seess, the preservation of the Litten's phenomenon in the latter two 
affections may be of great value in diagnosis. Very large accumu- 
lations of ascitic fluid may so far restrain the diaphragmatic move- 
ments that no shadow can be seen. Great muscular weakness or 
debility may greatly diminish, but rarely if ever prevent, the excur- 




Fig. 56.— Excursion of the Diaphragm during Forced Respiration. R, Ribs ; E, position of 
the diaphragm at end of expiration ; I, position of diaphragm at end of inspiration. 



sion of the shadow. In persons who cannot be made to breathe 
deeply enough to bring it out, a hard cough will frequently render 
it visible. 

The use of this method of examination tends, to a certain ex- 
tent, to free us from the necessity of using the sc-rays, inasmuch as 



INSPECTION, 79 

it furnishes us with the means of observing the diaphragmatic 
movements, on the importance of which so much stress has been 
laid by F. H. Williams and others, much more easily and cheaply 
than with the arrays, and upon the left side, more plainly as well. 

It also frees us to a considerable extent from the need of using 
the spirometer to determine the capacity of the lungs. 

By measuring the excursion of the phrenic shadow and taking 
account of the thoracic movement, we obta,in a very fair idea of the 
respiratory capacity of the individual. 

VII. Observation of the Cardiac Movements. 
(1) The Normal Cardiac Impulse. 

With each systole of the heart there may be seen in the great 
majority of normal chests an outward movement of a small portion 
of the chest wall just inside and below the left nipple. This phe- 
nomenon is known as the cardiac impulse. 1 It is now generally 
admitted that the " apex impulse " is caused by the impact of a 
portion of the right ventricle against the chest wall and not by the 
apex of the heart itself. [The bearings of this fact, which have 
not, I think, been generally appreciated, will be discussed pres- 
ently.] The position of the maximum impulse in adults is usually 
in the fifth intercostal space just inside the nipple line. In chil- 
dren under the age of six it is often in the fourth interspace or 
behind the fifth rib ; while in persons of advanced age it often de- 
scends as low as the sixth interspace. In adults it is occasionally 
absent even in perfect health and under certain pathological condi- 
tions to be later mentioned. 

(a) The position of the impulse varies to a certain extent ac- 
cording to the position of the body. If the patient lies upon the 
left side, the heart's apex swings out toward the axilla, so that 
the visible impulse shifts from one to two and one-half inches to 
the left (see Fig. 57). A slight shift to the right can also be 
brought about by lying upon the right side, and, as a rule, the im- 
pulse is less visible in the recumbent than in the upright position. 

1 For a more detailed description of the normal position of the cardiac 
impulse, see next page. 



80 



PHYSICAL DIAGNOSIS. 



Since the heart is lifted with each expiration by the rise of the dia- 
phragm and falls during inspiration, a corresponding change can be 
observed in the apex beat, which, in forced breathing, may shift as 
much as one interspace. Of the changes in the position of the im- 
pulse brought about by disease, I shall speak in a later paragraph. 




Fig. 57.— Showing Amount of Shifting of the Apex Impulse with Change of Position. The in- 
ner dot represents the position of the impulse when the patient lies on his back ; the outer 
dot corresponds to the position of the apex with patient on left side. 



(b) Relation of the maximum cardiac impulse to the apex of the 
heart. — I mentioned above that the maximum cardiac impulse is not 
due to the striking of the apex of the heart against the chest wall, 
but to the impact of a portion of the right ventricle. The practical 
importance of this fact is this: When we are trying to localize the 
apex of the heart in order to determine how far the organ extends 
to the left and downward, it will not do to be glided by the posi- 



INSPECTION. 



81 



tion of the maximum impulse, for the apex of the heart is almost 
always to be found three-fourths of an inch or more farther to the 
left (see Fig. 58) . This may be proved by percussion (vide infra, 




Fig. 58.— The Inner Dot is the Maximum Cardiac Impulse. That to the right is the true apex 
of the heart, as obtained by percussion. The ribs are numbered. 



p. 58). The true position of the cardiac apex thus determined cor- 
responds usually not with the maximum impulse, but with the point 
farthest out and farthest down at which any rise and fall syn- 
chronous with the heart beat can be felt (for further discussion of 
this point see below, p. 272). 

(c) Besides the definite and localized impulse which has just 

been described, it is often possible to see that a considerable section 

of the chest wall in the precordial region is lifted "en masse." 

The phenomenon is the " Herzenstoss " of the Germans, with which 

6 



82 PHYSICAL DIAGNOSIS. 

the i: Sjritze?istoss " or apex impulse is contrasted. A variable 
amount of " Herzenstoss " can be seen and felt over any normal 
heart when it is acting rapidly and forcibly, and in thin, nervons 
subjects or in children even when the heart is beating quietly. It 
is more marked in cardiac neuroses or in cases in which the heart 
is hypertrophied and in which there is more or less stiffening of the 
ribs with loss of their natural elasticity. At times it may be 
impossible to localize any one point to which we can give the 
name of apex impulse, and what we see is the rhythmical rise and 
fall of a section of the chest as large as the palm of the hand or 
larger. 

(d) Character of the cardiac impulse. — Palpation is considerably 
more effective than inspection in giving us information as to the na- 
ture of the cardiac movements which give rise to the "apex beat," 
but even inspection sometimes suffices to show that the impulse has 
a heaving character or is of the nature of a short tap, a peristaltic 
wave, or a diffuse slap against the chest wall. In some cases a dis- 
tinct undulation can be seen passing from the apex region upward 
toward the base of the heart, or less often in the opposite direction. 

(2.) Displacement of the Cardiac Impulse. 

To one familiar with the position, extent, and character of the 
normal cardiac impulse, any displacement of this impulse from its 
normal site or any superadded pulsation in another part of the chest 
is apparent at a glance. I will consider first the commonest forms 
of dislocation of the apex impulse. 

(a) Displacement of the cardiac impulse due to hypertrophy and 
dilatation of the heart. — By far the most common directions of dis- 
placement are toward the left axilla, or downward. As a rule, it 
is displaced in both these directions at once. I shall return to this 
subject more in detail under the heading Cardiac Hypertrophy, but 
here I may say that enlargements of the left ventricle tend espe- 
cially to displace the apex impulse downward, while enlargements of 
the right ventricle are more commonly associated with displacement 
of the impulse toward the axilla. 

(ft) Next to hypertrophy and dilatation of the heart perhaps the 
commonest cause of dislocation of the cardiac impulse is pressure 



INSPECTION. 



83 



from below the diaphragm. When the diaphragm is raised by a 
large accumulation of gas or fluid or by solid tumors of large size, 
we may see the apex beat in the fourth interspace and often an inch 
or more inside the nipnle line. 

(c) Of nearly equal frequency is displacement of the heart due 
to pleuritic effusion or to pneumothorax (see below, p. 336). 

When a considerable amount of air or fluid accumulates in the 
left pleural cavity, the apex of the heart is displaced to the right 
so that it may be concealed behind the sternum or be visible beyond 
it to the right ; in extreme cases it may be dislocated as far as the 
right nipple. Eight pleuritic effusions have far less effect upon 
the position of the cardiac impulse, but when a very large amount 
of fluid accumulates we may see the impulse displaced considerably 
toward the left axilla 

(d) I have mentioned causes tending to push the heart to the 
right, to the left, or upward. Occasionally the heart is pushed 
downward by an aneurismal tumor or a neoplasm of the mediasti- 
num. In these cases there is usually more or less displacement to 
the left as well. As a result of arteriosclerosis or cardiac hyper- 
trophy the aorta may sag or stretch a little, and the diaphragm 
stands lower, and hence the apex beat may descend to the sixth in- 
terspace, or (more often) it may be lost to sight and touch behind 
the bunch of convergent costal cartilages just to the left of the 
ensiform. Very frequently in men past forty-five the whole heart 
sinks considerably, so that a marked systolic retraction (less often 
pulsation) is seen below the ensiform in the epigastrium. 

(e) Displacement of the cardiac impulse resulting from adhesions 
of the pericardium, or of the pleura, with subsequent contraction, 
occurs in fibroid phthisis and in some cases of long-standing disease 
of the pleura. Through the effect of negative pressure the heart 
may be sucked into the space formerly occupied by a portion of the 
lung, when the latter has become contracted by disease. It seems 
likely, however, that in the majority of cases adhesions between 
the pleura and pericardium play a part in such displacement. By 
these means the heart may be displaced to the right of the sternum, 
as it is by left-sided pleuritic effusion. It is often drawn upward 



84 PHYSICAL DIAGNOSIS. 

as well as to the right in such cases by the contraction which takes 
place in the upper part of the lung. More rarely we may see the 
heart drawn toward the left clavicle in fibroid phthisis of the left 
apex. 

(/) Distortion of the thorax due to spinal curvature or other 
causes may bring about a considerable displacement of the heart 
from its normal position. 

(g) Dextrocardia and Situs Inversus. — In rare cases a displace- 
ment of the apex impulse to the right of the sternum may be due 
either to a transposition of all viscera [the liver being found upon 
the left, the spleen upon the right, etc.], or to dextrocardia, in which 
the heart alone is transposed while the other viscera retain their 
normal places. 

Summary. 
The apex impulse is displaced by 

(a) Hypertrophy and dilatation of the heart. 

(b) Pressure from below the diaphragm. 

(c) Air or fluid in one pleural cavity, especially the left. 

(d) Aneurism, mediastinal growths, and sagging of the aorta. 

(e) Fibroid phthisis. 
(/) Spinal curvature. 

((/) Transposition of the heart or of all the viscera. 

(3) Apex Retraction. 
Before leaving the subject of the cardiac impulse it seems best 
to speak of those cases in which during systole we see a retraction 
of one or more interspaces at or near the point where the cardiac 
impulse normally appears. 

(a) In by far the greater number of instances such retraction is 
due to negative pressure produced within the chest by the vigorous 
contraction of a more or less hypertrophied and dilated heart. In 
these cases the retraction is usually to be seen in several inter- 
spaces. Such retraction is not at all uncommon and usually at- 
tracts no attention. 

(b) In rarer cases several interspaces, both in the precordial 



INSPECTION. 



85 



region and in the left lower axilla and back, may be drawn in as a 
result of adhesions between the pericardium and the chest wall, 
such as form in cases of adherent pericardium and fibrous medias- 
tinitis (see below, pages 276 and 303.) 

(4) Epigastric Pulsation. 

In a considerable portion of healthy adults a pulsation or retrac- 
tion at the epigastrium synchronous with the systole of the heart is 
to be seen from time to time. Such pulsation has often been treated 
as evidence of hypertrophy of the right ventricle of the heart, but 
this I believe to be an error. It is not at all uncommon to find, 
post mortem, considerable hypertrophy of the right ventricle in cases 
in which during life no epigastric pulsation has been visible, while, 
on the other hand, the heart is frequently found normal at autopsy 
in cases in which during life there has been marked epigastric pul- 
sation.* In some cases such pulsation is to be explained as the 
transmission of the heart's impulse through the liver, or as a lifting 
of that organ by the movements of the abdominal aortao In other 
cases it is due to bathycardia (" low heart "" — a condition very com- 
mon in arteriosclerosis). 

(5) Visible Pulsations clue to Uncovering of Portions of the Heart 
Normally Covered by the Lungs. 

One of the commonest causes of visible pulsations in parts of 
the chest where normally none is to be seen is retraction of the 
lung. 

(a) It is in chlorosis, perhaps, that we most frequently see 
such pulsations. In that disease, as in other debilitated states, the 
lungs are often not adequately expanded owing to the superficiality 
of the respiration, and accordingly their margins do not cover as 
much of the surface of the heart as they do in healthy adults. 
This results in rendering visible, in the second, third, or fourth left 
interspace near the sternum, pulsations transmitted from the conus 
arteriosus or from the right ventricle. Less commonly, similar pul- 
sations may be seen on the right side of the sternum. 

(b) A rarer cause of retraction of the lungs is fibroid phthisis 
or chronic interstitial pneumonia. In these diseases a very large 



86 



PHYSICAL DIAGNOSIS. 



area of pulsation may be seen in the precordial region owing to the 
entire uncovering of the heart by the retracted lung, even when the 
heart is not drawn out of its normal position. 

VIII. Aneurism and Other Causes of Abnormal Thoracic 

Pulsation. 

So far I have spoken altogether of pulsations transmitted di- 
rectly to the thorax by the heart itself, but we have also to bear in 




Fig. 59.— Position When Looking for Slight Aneurismal Pulsation. 

mind that a dilated aorta may transmit to the chest wall pulsations 
which it is exceedingly important for us to recognize and properly to 
interpret. No disease is easier to recognize than aneurism when the 
growth has perforated the chest wall and appears as a tumor exter- 
nally, but it is much more important as well as much more difficult 
to recognize the disease while it is confined within the thorax. In 
such cases, the movements transmitted from the aorta to the chest 
wall may be so slight that only the keenest and most thorough in- 
spection controlled by palpation will detect them. When slight 
pulsations are searched for, the patient should be put in a position 



INSPECTION. 87 

shown in Fig. 59, and the observer should place himself so that his 
eye is as nearly as possible on a level with the chest and looks 
across it so that he sees it in profile. In this position, or in a sitting 
position with tangential light, he can make out pulsations which are 
totally invisible if the patient sits facing the light. 

Pulsations due to aneurism are most apt to be seen in the first 
or second right interspace near the sternum, and not infrequently 
the clavicle and the adjacent parts may be seen to rise slightly with 
every beat of the heart, but in any part of the chest wall pulsa- 
tions due to an aneurism are occasionally to be seen, and should be 
looked for scrupulously whenever the symptoms of the case suggest 
the possibility of this disease (see below, p. 281). 

Pulsating Pleurisy. 

In cases of purulent pleurisy in which the pus has worked its 
way out betwen the ribs so that it is covered only by the skin and 
subcutaneous tissues, a pulsation transmitted from the heart may 
become visible, and the resemblance to the pulsation seen in aneu- 
rism may be confusing. Such pulsation is apt to be seen in the 
upper and front portions of the chest. Very rarely a pleuritic effu- 
sion which has not burrowed into the chest wall may transmit to 
the latter a wavy movement corresponding to the motions set up 
in the fluid by the cardiac contractions. 

IX. Inspection of the Peripheral Vessels. 

In a work dealing with diseases of the heart and lungs it is im- 
possible to avoid reference to vascular phenomena apparent in the 
neck or in the extremities, since such phenomena have a very direct 
bearing upon the interpretation of the conditions obtaining within 
the chest. Inspection plays a very large part in the study of these 
vascular phenomena. We should look for ; 

(a) Venous phenomena. 

(b) Arterial phenomena. 

(c) Capillary phenomena. 



88 PHYSICAL DIAGNOSIS. 



(a) Inspection of the Veins. 

1. The condition of the veins of the neck is of considerable im- 
portance in the diagnosis of diseases of the heart and lungs. Where 
the tissues of the neck are more or less wasted the veins may be 
quite prominent even when no disease exists within the chest, and 
in such cases they may be more or less distended during each expi- 
ration, especially if dyspnoea or cough is present. If the over- 
distended veins are completely emptied during deep inspiration 
and on both sides of the neck, we can usually infer that there is an 
overdistention of the right side of the heart. When a similar 
phenomenon occurs on one side only, it may mean pressure upon 
one innominate vein. So far I have spoken of venous changes 
synchronous with respiration, but we may have also 

2. A presystolic pulsation or undulation seen either in the ex- 
ternal jugular vein or in the bulbus jugularis between the two 
attachments of the stern omastoid muscles. Such pulsation or 
undulation, which is to be seen just before each systole of the 
heart, is not necessarily anything abnormal and must be carefully 
distinguished from 

3. Systolic venous jmlsation, such as occurs in one of the most 
serious valvular diseases of the heart — tricuspid regurgitation. 1 
Systolic venous pulsation is more often seen upon the right side 
than upon the left side of the neck. There may be a wave during 
the systole of the auricle and another during the systole of the ven- 
tricle, the latter closely following the former. In any case in 
which a doubt arises whether a pulsation in the veins of the neck 
is due to tricuspid regurgitation, it is well to try the experiment of 
emptying the vein by stroking it from below upward. If it imme- 
diately fills from below, we may be practically certain that tricus- 
pid regurgitation is present. In the vast majority of cases of ve- 
nous pulsation due to other causes or occurring in healthy persons 

1 A pulsating carotid may transmit an up-and-down motion to the veins 
overlying it. In such cases, if the veins be emptied by "milking" them up- 
ward, they will not refill from below. 



INSPECTION. 



89 



a vein will not refill from below if emptied in the manner above 
described. 

4. Rarely, superficial veins may be seen to pulsate in other parts 
of the body, especially in aortic regurgitation, and occasionally 
large and tortuous veins may be seen pulsating upon the thoracic 




Fig. 60.— Tortuous Veins on Chest and Abdomen. (Autopsy showed obliteration of the vena 

cava inferior.) 

or abdominal wall, representing an attempt at collateral circulation 
when one or the other vena cava is compressed (Fig. 60). 

(b) Arterial Phenomena. 

1. In thin or nervous persons pulsations are not infrequently to 
be seen in the carotids independent of any abnormal condition of 
the heart. 

2. Very violent throbbing of the carotids, more noticeable than 



90 



PHYSICAL DIAGNOSIS. 



that seen in health, occurs in many cases of aortic regurgitation 
and occasionally in simple hypertrophy of the heart without any 
valvular disease. From the same causes, visible pulsation may 
occur in the subclavian, axillary, brachial, and radial arteries, as 
well as in the large arterial trunks of the lower extremity. 

I lately examined a blacksmith whose heart was considerably 
enlarged by hard work, but without any valvular disease. Pulsa- 




Fig. 61.— Enlarged Tortuous Brachial Arteries (Arterio-sclerosis). 



tion was violent in all the peripheral arteries which I have just 
named. 

3. In arterio-sclerosis occurring in spare, elderly men, with or 
without aortic regurgitation, one often notices a lateral excursion of 
the tortuous brachial arteries synchronous with every heart beat. 
An up-and-down pulsation may occur at the same time. Not infre- 
quently the arteries which are stiffened by deposition of lime salts 
(see below, page 110) stand out visibly as enlarged, tortuous cords 
upon the temple and along the inner sides of the biceps muscle, 
(see Figs. 61 and 62) and occasionally the course of the radial artery 



INSPECTION. 91 

may be traced over a considerable distance in the forearm. In rare 
cases inequalities produced in the arterial wall by deposition of 
lime salts may be visible as well as palpable. 

(c) Capillar y Pulsation. 

If a microscopic slide is placed against the mucous membrane of 
the lower lip so as partially to blanch its surface, one may see, with 




•V 



Fig. 62.— Enlarged and Tortuous Brachial Artery ( Arterio-sclerosis) . 

each beat of the heart (in cases of aortic regurgitation and sometimes 
in other conditions), a delicate flushing of the blanched surface be- 
neath the glass slide. The same pulsation is sometimes to be ob- 
served under the finger nails, or may be still better brought out by 
drawing a pencil or other hard substance across the forehead so as 
to cause a line of hyperemia, at the edge of which the systolic flush- 
ing occurs. This phenomenon will be referred to again when we 
come to speak of aortic regurgitation. Here it suffices to say that 
it is not in any way peculiar to that disease, and occurs occasion- 



92 PHYSICAL DIAGNOSIS. 

ally in health, in anaemia, in exophthalmic goitre, and in condi- 
tions associated with low tension in the peripheral arteries, as well 
as in any area of inflammatory hyperamiia (jumping toothache, 
throbbing felon, etc.). 

X. Inspection of the Skin and Mucous Membranes. 

Light may be thrown upon the diagnosis of diseases of the chest 
by observing the color and condition of the cutaneous surfaces as 
well as of the mucous membranes. We should look for the follow- 



ing conditions : 




(1) Cyanosis. 




(2) (Edema. 




(3) Pallor. 




(4) Jaundice. 




(5) Scars and eruptions. 






(1) Cyanosis. 



By cyanosis we mean a purplish or grayish-blue tint notice- 
able especially in the face, in the lips, and under the nails. There 
are many degrees of cyanosis, from the slight purplish tinge of the 
lips, which a little overexertion or slight exposure to cold may bring 
out, up to the gray -blue color seen in advanced cases of pulmonary or 
cardiac disease, or the dark reddish-blue seen in congenital malfor- 
mations of the heart. Cyanosis makes a very different impression 
upon us when it is combined with pallor on the one hand or with 
jaundice on the other. When combined with pallor, one gets vari- 
ous ashy-gray tints, while the admixture of cyanosis and jaundice 
results in a color very difficult to describe, sometimes approaching 
a greenish hue. The commonest causes of cyanosis are : 

(a) Valvular or parietal disease of the heart. 

(b) Emphysema. 

(c) Asthma. 

(d) Pneumonia. 

(e) Phthisis. 

(/) In some persons a certain degree of cyanosis of the lips 
exists despite perfect health. This is especially true of weather- 
beaten faces and those of the so-called " full-blooded " type. 



INSPECTION. 93 

(g) Methaemoglobinaemia, such as occurs after the excessive use 
of coal-tar aualgesics (antifebrine, etc.). 

A rare but very striking type of cyanosis is that seen in cases 
of congenital heart disease, in which the lips may be indigo blue 
in color or 'almost black while yet no dyspnoea is present. 

(2) (Edema. 

(Edema, or the accumulation of serous fluid in the subcutaneous 
spaces, is usually appreciated by palpation rather than by inspec- 
tion, but sometimes makes the face look very puffy, especially 
under the eyes This is not a common occurrence in diseases of 
the chest, in connection with which such oedema as takes place is 
usually to be found in the lower extremities and is appreciable 
rather by palpation than by inspection. If we are not familiar with 
a patient's face, we often do not perceive in it the changes of out- 
line due to oedema which a friend would notice at once. Clothing 
is apt to leave grooves and marks wherever it presses tightly upon 
the oedematous tissues, as around the waist or over the shoulders. 
In the legs, the presence of oedema may be suggested by an unnatu- 
rally smooth, glossy appearance of the skin Such impressions, 
however, may be false unless controlled by palpation, for simple 
obesity may produce very similar appearances. 

(3) Pallor. 

Pallor suggests, though it does not in any way prove, anaemia, 
and anaemia is a characteristic of the commonest of all diseases of 
the chest — phthisis. It is also seen in certain varieties of cardiac 
disease. Pallor of the mucous membranes, as seen in the lips and 
conjunctivae, is much more apt to be a sign of real anaemia than is 
pallor of the skin. At best, pallor is only a sign which suggests to 
us to look further into the case in one or another direction, and of 
itself proves nothing of importance. 

(4) Jaundice. 
The yellowish tint which appears in the skin, and especially in 



94 



PHYSICAL DIAGNOSIS. 



the conjunctivae, when the escape of bile from the liver is hindered, 
is sometimes to be seen in connection with uncompensated heart 
disease when the liver is greatly distended by passive congestion 
Pneumonia is occasionally complicated by jaundice; but beyond 
this I know of no special connection between this symptom and 
diseases of the chest. 

(5) Scars and Eruptions. 

In cases of suspected syphilis of the lung or bronchi the pres- 
ence of scars and eruptions suggestive of syphilis may be useful in 
diagnosis. 




Fig. 63.— Sarcoma of Sternum and Cervical Glands. (Curschmann.) 
XI. Enlarged Glands. 

Routine inspection of the chest may reveal the presence of en- 
larged glands in the neck or axillae, and may thereby give us a clew 



INSPECTION. 95 

to the nature of some intrathoracic disease ; for example, the pres- 
ence of enlarged glands in the neck, especially if there are any 
scars, sinuses, or other evidence that suppuration is going on or 
has formerly taken place in them, suggests the possibility of pul- 
monary tuberculosis or of an enlargement of the bronchial and me- 
diastinal glands. Again, malignant disease of the chest is some- 
times associated with the metastatic nodules over the clavicle (see 
Fig. 63), and a microscopic examination of them may thus reveal 
the nature of the intrathoracic disease to which they are secondary. 
Very large and matted masses of glands above the clavicle, which 
have never suppurated and have been painless and slow in their 
growth, suggest the presence of similar deposits in the mediastinum 
as a part of the symptom complex known as "Hodgkin's disease." 
The presence of a goitre or enlargement of the thyroid gland may 
account for a well-marked dyspnoea. 

Syphilis produces general glandular enlargement; the posterior 
cervical and the epitrochlear glands are often involved, but this is 
also the case in many diseases other than syphilis. 



CHAPTER V. 

PALPATION AND THE STUDY OF THE PULSE. 

I Palpation. 

The most important points to be determined by palpation — that 
is, by laying the hand upon the surface of the chest — are : 

(1) The position and character of the apex beat of the heart. 

(2) The presence of a "thrill" (see below). 

(3) The vibrations of the spoken voice (" tactile fremitus"}. 

(4) The presence of pleuritic or pericardial friction. 

Other less important data furnished by palpation will be men- 
tioned later. 

(1) The Apex Beat. 

(a) In feeling for the apex impulse of the heart, one should 
first lay the palm of the hand lightly upon the chest just below the 
left nipple In this way we can appreciate a good deal about the 
movements of the heart, and confirm or modify what we have 
learned by inspection. One learns, in the first place, whether the 
heart beat is regular or not, and in case it is irregular, whether the 
beats are unequal in force or whether some are skipped; further, 
one gets a more accurate idea than can be obtained through inspec- 
tion regarding the character of the cardiac movements. The power- 
ful heaving impulse suggesting a hypertrophic d heart, the diffuse 
slap often felt in dilatation of the right ventricle, the sudden tap 
characteristic of mitral stenosis, the deliberate thrust occasionally 
met with in aortic stenosis, may be thus appreciated. 

(b) After this, it is best to lay the tips of two or three fingers 
over the point where the maximum impulse is to be seen, and fol- 
low it outward and downward until one arrives at the point farthest 
to the left and farthest down at which it is still possible to feel 



PALPATION AND THE STUDY OF THE PULSE. 97 

any up-and-down movement. This point usually corresponds with 
the apex of the heart, as determined by percussion. It does not 
correspond with the maximum cardiac impulse, but is often to be 
found at least an inch farther to the left and downward (see above, 
Fig. 5$). 

Sometimes one can localize by palpation a cardiac impulse 
which is not visible ; on the other hand, in some cases we can see 
pulsations that we cannot feel. Both methods must be used in 
every case. 

The results obtained by palpation and inspection of the apex 
region give us the most reliable data that we have regarding the 
size of the heart. Percussion may be interfered with by the pres- 
ence of gas in the stomach, of fluid or adhesions in the pleural cav- 
ity, or by the ineptness of the observer, but it is almost always pos- 
sible with a little care to make out by a combination of palpation 
and inspection the position of the apex of the heart. When we 
can neither feel it nor see it, we may have to fall back upon auscul- 
tation, considering the apex of the heart to be at or near the point 
at which the heart sounds are heard loudest. When endeavoring 
to find the apex of the heart, we must not forget that the position 
of the patient influences considerably the relation of the heart to 
the chest walls If the patient is leaning toward the left or lying 
on the left side, the apex will swing out several centimetres toward 
the left axilla, 

(2) "Thrills." 

When feeling for the cardiac impulse with the palm of the 
hand, we are in a good position to notice the presence or absence 
of a very important physical sign to which we give the name of 
"thrill." The feeling imparted to the fingers by the throat of 
a purring cat is very much like the palpable " thrill " over the pre- 
cordia in certain diseases of the heart to be mentioned later. It is 
a vibration of the chest wall, usually confined to a small area in the 
region of the apex impulse, but sometimes felt in the second right 
intercostal space or elsewhere in the precordial region. This vibra- 
tion or thrill almost always occurs intermittently, i.e., only during 
7 



98 PHYSICAL DIAGNOSIS. 

9b portion of the cardiac cycle, When felt in the apex region, it 
usually occurs just before the cardiac impulse ; this fact we express 
by calling it a " presystolic thrill "; but occasionally Ave may feel a 
systolic thrill at the apex — one, that is, which accompanies the car- 
diac impulse. The word thrill should be used to denote only a 
purring, vibrating sensation communicated to the fingers by the 
chest wall. It is incorrect to speak of a thrill as if it were some- 
thing audible. 

We must also distinguish a purring thrill from the slight shud- 
der or jarring which often accompanies the cardiac impulse in func- 
tional neuroses of the heart or in conditions of mental excitement. 

As a rule we can appreciate a thrill more easily if we lay the 
fingers very lightly upon the chest, using as little pressure as pos- 
sible. Firm pressure may prevent the occurrence of the vibrations 
which we desire to investigate. Of the thrills felt over the base of 
the heart, more will be said in Chapter X. 

(3) Vibrations Communicated to the Chest Wall by the Voice. 

il Tactile fremitus " is the name given to the sense of vibration 
communicated to the hand if the latter is laid upon the chest while 
the patient repeats some short phrase of words. The classical 
method of testing tactile fremitus is to ask the patient to count 
"one, two, three," or to repeat the words "ninety -nine " while the 
palm of the hand is laid flat upon the chest. The amount of fre- 
mitus to be obtained over a given part of the thorax varies, of course, 
according to the loudness of the words spoken, and is influenced 
also by the vowels contained in them. A certain uniformity is ob- 
tained by getting the patient to repeat always the same formula. 
Thus, he is likely to use the same amount of force each time he re- 
peats them and to use approximately the same pitch of voice. 

Other things being equal, the fremitus is greater in men than 
in women, in adults than in children, and is more marked in those 
whose voices are low pitched than in those whose voices are rela- 
tively shrill. The amount of fremitus also varies widely in differ- 
ent parts of the healthy chest A glance at Fig 64 will help us to 
realize this The parts shaded darkest communicate to the fingers 



PALPATION AND THE STUDY OF THE PULSE. 



99 



the most marked fremitus, while in the parts not shaded at all, lit- 
tle or no fremitus is felt. Intermediate degrees of vibration are 
represented by intermediate tints of shading. From this diagram 
we see at once (a) that the maximum of fremitus is to be obtained 
over the apex of the right lung in front, (b) that it is greater in the 
upper part of the chest than in the lower, and somewhat greater 
throughout the right chest than in corresponding parts of the left. 




Fig. 64.— Distribution of Tactile Fremitus. 



This natural inequality of the two sides of the chest cannot be too 
strongly emphasized. 

Comparatively little fremitus is to be felt over the scapulae be- 
hind, and still less in the precordial region in front. The outlines 
of the lungs can be quite accurately mapped out by means of the 
tactile fremitus in adults of low-pitched voice. In children, as has 
been already mentioned, fremitus is usually very slight and may be 
entirely absent, and in many women it is too slight to be of any 
considerable diagnostic value. Again, some very fat persons and 
those with thick chest walls transmit but little vibration to their 
chest walls when they speak. On the other hand, in emaciated 
patients or in those with thin-walled, flexible chests, the amount 
of fremitus is relatively great. 



ioo 



PHYSICAL DIAGNOSIS. 



Bearing in mind all these disparities — disparities both between 
persons of different age and different sex, and between the two 

sides of the chest in any one 
person — we are in a position to 
appreciate the modifications to 
which disease gives rise and 
which may be of great impor- 
tance in diagnosis. These vari- 
ations are : 

(a) Diminution or absence 
of fremitus. 

(b) Increase or absence of 
fremitus. 

(a) If the lung is pushed 
away from the chest wall by the 
presence of air or fluid or tumor 
in the pleural cavity, we get a 
diminution or absence of tactile 
fremitus — diminution where the 
layer of fluid or air is very thin, 
absence where it is of consider- 
able thickness. 

(b) Solidification of the lung 
due to phthisis or pneumonia is 
the commonest cause of an in- 
crease in tactile fremitus. Fur- 
ther details as to the variations 

in amount of fremitus in different diseases may be found in later 
chapters of this book. 

(4) Friction, Pleural or Pericardial. 

In many cases of inflammatory roughening of the pleural sur- 
faces ("dry pleurisy") a grating or rubbing of the two surfaces 
upon each other may be felt as well as heard during the movements 
of respiration, and especially at the end of inspiration. Such fric- 
tion is most often felt at the bottom of the axilla, on one side or 




Fig. 65. -Showing Point (F) at Which Pleural 
Friction is Most Often Heard. 



PALPATION AND THE STUDY OF THE PULSE. 



101 



the other, where the diaphragmatic pleura is in close apposition 
with the costal layer (see Fig. 65, p. 100). 

Similarly, in roughening of the pericardial surfaces ("dry" or 
" plastic " pericarditis) it is occasionally possible to feel a grating 
or rubbing in the precordial region more or less synchronous with 
the heart's movements. Such friction is most often to be felt in 
the region of the fourth left costal cartilage (see Fig. 66). 

Palpable friction is of great value in diagnosis because it is a 
sign about which we can feel no doubt ; as such it frequently con- 




Fig. 66.— Showing Point (P) at Which Pericardial Friction is Most Often Heard. 

firms our judgment in cases in which the auscultatory signs are less 
clear. Friction sounds heard with the stethoscope may be closely 
simulated by the rubbing of the stethoscope upon the skin, but pal- 
pable friction is simulated by nothing else, unless occasionally by 

(5) Palpable Hales. 

Occasionally coarse, dry rales communicate a sensation to the 
hand placed upon the chest in the region beneath which the rales 
are produced; to the practised hand this sensation is quite differ- 
ent from that produced by pleural friction, although the difference 
is hard to describe. 



102 



PHYSICAL DIAGNOSIS. 



(6) Tender points upon the thorax. 

In intercostal neuralgia, dry pleurisy, necrosis of a rib, and 
sometimes in phthisis, one finds areas of marked tenderness in 
different parts of the chest. The position of the tender points in 
intercostal neuralgia generally corresponds with the point of exit 
of the intercostal nerves. These points are shown in Fig. 67. 

The tenderness in phthisis is most apt to be in the upper and 
front portions of the chest. In neurotic individuals we sometimes 
find a very superficial tenderness over parts of the thorax ; in such 




Fig. 67.— Showing Points of Exit of the Intercostal Nerves. 



cases pain is produced by very light pressure, but not by firm press- 
ure at the same point. 

(7) The presence of pulsations in parts of the chest where nor- 
mally there should be none is suggested by inspection and con- 
firmed by palpation. It is not necessary to repeat what was said 
above as to the commonest causes of such abnormal pulsations. 
When searching for slight, deep-seated pulsation (e.g., from an 
aortic aneurism), it is well to use bimanual palpation, keeping one 
hand on the front of the chest and the other over a corresponding 
area in the back. 

(8) Fluctuation or elasticity in any tumor or projection from 



PALPATION AND STUDY OF THE PULSE. 103 

the chest is a very important piece of information which palpation 
may give us. 

(9) The temperature and quality of the skin are often brought 
to our attention during palpation. After a little practice one can 
usually judge the temperature within a degree or two simply from 
the feeling of the skin. Any roughness, dryness, or loss of elas- 
ticity of the skin (myxoedenia, diabetes, long-standing pyrexia, or 
wasting disease) is easily appreciated as we pass the hand over the 
surface of the thorax or clown the arms. The same manipulation 
often brings to our attention in cases of alcoholism an unusually 
smooth and satiny quality of the cutaneous surface. 

II. The Pulse. 

Fifty years ago the study of the pulse furnished the physician 
with most of the available evidence regarding the condition of the 
heart. At present this is not the case. With the increase of our 
knowledge of the direct physical examination of the heart and of ' 
the various methods of measuring the systolic or diastolic pressure 
on the peripheral arteries, the amount of information furnished 
exclusively by the pulse has proportionately decreased, until to- _ 
day, I think, it is a fact that there is but little to be learned by 
studying the pulse which could not be as well or better ascertained 
by examining the heart and measuring the arterial pressure. 

Nevertheless, the radial pulse is still an important factor in diag- 
nosis, prognosis, and treatment, and will remain so, because it gives ' 
us quickly, succinctly, and in almost every case a great deal of valu- 
able information which it would take more time and trouble to ob- 
tain in any other way. As we feel the pulse, we get at once a fact 
of central importance in the case; by the pulse the steps of our sub- 
sequent examination are guided. In emergencies or accidents the 
pulse gives us our bearings and tells us whether or not the patient's 
condition is one demanding immediate succor — e.g., hypodermic 
stimulation — and whether the outlook is bright or dark. To gather 
this same information in any other way would involve losing valu- 
able time. 

Again, when one has to to see a large number of patients in a 



104 PHYSICAL DIAGNOSIS. 

short time, as in visiting a hospital ward or on the crowded days of 
private practice, the pulse is an invaluable short cut to some of the 
most important data. 

Moreover, there are some important inferences which the pulse 
and only the pulse enables us to make. They are not numerous, but 
their value may be great. Delay in one radial pulse when taken in 
connection with other signs may furnish decisive evidence of aneu- 
rism of the aortic arch ; aortic stenosis is a lesion which cannot be 
diagnosed unless the pulse shows certain characteristic features ; 
arterial degeneration may betray its presence chiefly in the periph- 
eral arteries. 

Since, then, the condition of the pulse furnishes information of 
crucial importance in a few diseases, and is a quick, reliable, and 
convenient indication of the general condition of the circulation in 
all cases, it is essential that we should study it most carefully both 
in health and in disease. 

How to Feel the Pulse. 

(a) We usually feel for the pulse in the radial artery because 
this is the most superficial vessel which is readily available. Oc- 
casionally, as when the wrists are swathed in surgical dressings or 
tied up in a straight- jacket, we make use of the temporal, facial, 
or carotid arteries. 

(b) Both radials should always be felt at the same time. By 
making this a routine practice many mistakes are avoided and any 
difference in the two pulses is appreciated. 

(c) The tips of three fingers (never the thumb) should be laid 
upon the artery, and the following points noted : 

1. The rate of the pulse. 

2. The rhythm of the pulse (regular or irregular). 

3. The amount of force necessary to obliterate it {compressi- 
bility). 

4. The size and shape of the pulse wave. 

5. The extent to which the artery collapses between beats 
(tension). 

6. The size and position of the artery. 



PALPATION AND THE STUDY OF THE PULSE. 105 

7. The condition of the artery walls. 

Each of these points will now be considered in detail. 

1. The Rate of the Pulse. 

In the adult male the pulse averages 72 to the minute, in the 
female 80. In children it is considerably more frequent. At birth 
it averages about 130, and until the third year it is usually above 
100. In some families as low pulse, 60 or less, is hereditary ; on the 
other hand, it is not very rare to observe a permanent pulse rate of 
100 or more in a normal adult (see below, p. 261). Exercise or emo- 
tion quickens the pulse very markedly, and after food it is somewhat 
accelerated. Some account of the causes of pathological quicken- 
ing or slowing of the pulse will be found on pages 261 and 262. 

2. Rhythm. 

The pulse may be irregular in force, in rhythm, or (as most 
commonly happens) in both respects. As a rule, irregularities in 
force are the more serious. Intermittence or irregularity in rhythm 
alone, means that the heart skips one or more beats at regular or 
irregular intervals. This may be a mere idiosyncrasy not associ- 
ated with any evidence of disease. I have known several instances 
in which a perfectly sound person has been aware of such an irregu- 
larity throughout life — the heart dropping regularly every third or 
fourth beat. Such rhythmical intermittence in health is not un- 
common. 

When beats are dropped, not at fixed intervals, but irregularly, 
the pulse waves usually vary in force as well. This combination 
of irregular cardiac rhythm with variations in the strength of the 
individual beats is very rarely seen in health and usually points to 
functional or structural disease of the heart. 

Special types of irregularity will be discussed later. 

In general it may be said (a) that irregularity in the force of 
the pulse beats is a serious sign, if overexertion and temporary 
toxic influences (tobacco, tea, etc.) can be ruled out; (b) that it is 
far more serious when occurring in connection with diseases of the 



106 PHYSICAL DIAGNOSIS. 

aortic valve than in mitral disease ; and (c) that it often occurs in 
connection with sclerosis of the coronary arteries and myocarditis. 

3. Compressibility, or Systolic Arterial Pressure. 

There is no single datum concerning the pulse more important 
than the amount of force needed to obliterate its beat. Until 
recently we have had no more accurate method of measuring the 
systolic blood pressure than the following : Let the tips of three 
fingers rest as usual on the radial artery Then gradually increase 
the pressure made upon the vessel with the finger nearest the pa- 
tient's heart until the pulse wave is arrested and cannot be felt by 
the other fingers which rest loosely on the artery. The degree of 
force necessary to arrest the wave varies a great deal in different 
cases and at different times of da}^ but by trying the above manoeuvre 
day after day in as many cases as possible, and especially by com- 
paring one's impressions with accurate measurements of blood press- 
ure (vide infra), one comes to possess a fairly accurate mental 
standard or picture of the compressibility of the average pulse, and 
is then able to estimate in any given case whether it is more or less 
compressible than usual. 

The compressibility of the pulse is a rough measure of the mus- 
cular power of the heart's beat, and therefore gives us direct infor- 
mation about this important element in the patient's condition. 

4. The Size and Shape of the Pulse Wave. 

Of the use of the sphygmograph for representing pulse waves 
I shall speak later. The points discussed in this section are appre- 
ciable to the fingers. 

I. The size of the pulse wave — the height to which it lifts the 
finger — depends on two factors : 

(a) The force of the cardiac contractions (systolic arterial 
pressure). 

(b) The tightness or looseness of the artery (tension, or diastolic 
pressure). 

If the arteries are contracted and small, the pulse wave corre- 



PALPATION AND THE STUDY OF THE PULSE. 107 

sponds, while if they are large and relaxed, it needs only a moder- 
ate degree of power in the heart to produce a high pulse wave. If 
the tension remains constant the size of the pulse wave depends on 
the force of the heart's contraction. If the heart power remains 
constant, the size of the pulse wave depends on the degree of vas- 
cular tension. Vascular tension is estimated in ways to be de- 
scribed presently, and after allowing for it, we are enabled to esti- 
mate the power of the heart's contractions from the height of the 
pulse wave. 

II. The shape of the pulse wave is also of importance. 

(a) It may have a very sharp summit, rising and falling back 
again suddenly; this is known as an ill- sustained pulse, and may 
be due to a lack of sustained propulsive power in the contracting 
heart muscle, to low vascular tension, or to a combination of the 
two causes. A weak heart with low arterial tension often produces 
such a pulse wave — deceptively high and giving at first an impres- 
sion of power in the heart wall, but ill sustained and easily com- 
pressible. This is the " bounding pulse " of early infectious proc- 
esses. An exaggeration, of this type of pulse is to be felt in aortic 
regurgitation (see page 232). 

(b) In sharp contrast with the above is the pulse wave which 
lifts the finger gradually and slowly, sustains it for a relatively 
long period, and then sinks gradually down again. Such a pulse 
with a " long plateau " instead of a sharp peak is to be felt most 
distinctly in aortic stenosis, less often in mitral stenosis and other 
conditions (see page 242). 

(c) The dicrotic pulse wave is one in which the secondary wave, 
which the sphygmograph shows to be present in the normal pulse, 
is much exaggerated, so that a distinct "echo" of the primary 
wave is felt after each beat. If the heart is acting rapidly, this 
dicrotic wave does not have time to fall before it is interrupted by 
the primary wave of the next beat, and so appears in the sphygmo- 
graphic tracing as a part of the up-stroke of the primary wave. 
This is known as the "anacrotic pulse." 

(d) The shape of the high-tension pulse wave will be described 
in the next paragraph. 



108 



PHYSICAL DIAGNOSIS. 



5. Tension, or Diastolic Arterial Pressure. 

The degree of contraction of the vascular muscles determines 
the size of the artery and (to a great extent) the tension of the 
blood within it. But if the heart is acting feebly, there may be so 
little blood in the arteries that even when tightly contracted they 
do not subject the blood within them to any considerable degree of 
tension. To produce high tension, then, we need two factors : a 




Fig. 68.— Sphygmographic Tracing of Low Tension Pulse. 

certain degree of power in the heart muscle, and contracted arteries. 
To produce low tension we need only relaxation of the arteries, and 
the heart may be either strong or weak. 

The pulse of low tension collapses between beats, so that the ar- 
tery is less palpable than usual or cannot be felt at all. Normally, 




Fig. 69.— Sphygmographic Tracing of High Tension Pulse. 

the artery can just be made out between beats, and any consider- 
able lowering of arterial tension makes it altogether impalpable 
except during the period of the primary wave and of the dicrotic 
wave, which is often very well marked in pulses of low tension. 
The shape of the wave under these conditions has already been 
described (see Fig. 68). 



PALPATION AND THE STUDY OF THE PULSE. 109 

The pulse of high tension is perceptible between beats as a dis- 
tinct cord which can be rolled between the fingers, like one of the ten- 
dons of the wrist. It is also difficult to compress in most cases, but 
this may depend rather on the heart's power than on the degree 
of vascular tension. A high-tension pulse is often indistinguishable 
from one stiffened by arteriosclerosis (vide infra). The pulse wave 
is usually of moderate height or low, and falls away slowly with 
little or no dicrotic wave (see Fig. 69). 

6. The Size and Position of the Artery. 

I have often known errors to occur because a small artery is 
mistaken for a small pulse wave. The size of the branches of the 
arterial tree varies a great deal in different individuals of the same 
weight and height, and if the radial is unusually small and a hur- 
ried observation gives us the impression (true, so far as it goes) that 
there is very little in the way of a pulse to be felt, we are apt to 
conclude (wrongly, perhaps) that the heart's work is not being 
properly performed. The effort to obliterate such a pulse, how- 
ever, may set us right by showing that despite the small size of the 
vessel (and consequently of the pulse wave) it takes as much force 
as it normally does to obliterate it. But in many cases we can 
determine the question satisfactorily often by using some instru- 
ment for measuring arterial pressure. Thus, a small pulse wave (in 
a congenitally small artery) may be distinguished from a weak 
pulse. From the contracted artery of high vascular tension we dis- 
tinguish the congenitally small. artery because the latter is not to be 
rolled beneath the fingers, and is not more than normally palpable 
between the pulse beats. 

Not infrequently the nurse reports in alarm that the patient has 
no pulse, when in reality the pulse is excellent but the artery mis- 
placed so as to be impalpable in the ordinary situation. It may be 
simply more deeply set than normal, so that the fingers cannot get 
at it, or it may run superficially over the end of the radius toward 
the "anatomical snuff box." Other anomalies are less common. 
As a rule, the other radial artery is normally placed and can be used 



110 PHYSICAL DIAGNOSIS. 

as a standard, but occasionally both radials are anomalous and we 
may be compelled to use the temporal or facial instead. 

7. The Condition of the Artery Walls. 

Arterio-sclerosis is manifested in the peripheral arteries in the 
following forms : 

(a) Simple stiffening of the arteries without calcification. 

(b) Tortuosity of the arteries 

(c) Calcification. 

Simple stiffening without calcification is due to fibrous thicken- 
ing of the mtima and produces a condition of the arteries not al- 
ways to be distinguished from high tension. The artery can be 
rolled under the fingers, stands out visibly between the heart's 
beats, but is not incompressible, has a smooth surface, and is not 
always tortuous. If it is tortuous as well as stiff, we may con- 
clude that there is endarteritis at any rate, whether or not there is 
increased tension as well. In the vast majority of cases the two 
conditions are asssociated and do not need to be distinguished. 

The normal radial artery is straight; hence any deviation is 
evidence of changes in its walls and is easily recognized as we run 
our fingers up and down the vessel. 

Calcification of the radial produces usually a beading of its sur- 
face. As we move the fingers along the artery, quickly and with 
very slight pressure, a series of transverse ridges or beads can be 
felt. The qualities of the pulse wave within can usually be appre- 
ciated fairly well, in this type of artery, but in very advanced cases 
the calcification is diffuse and converts the radial into a rigid " pipe 
stem " — absolutely incompressible — unless we break the calcified 
coat — and easily mistaken for a tendon. In such an artery no 
pulse can be felt. 

Such are the points to be observed in feeling the pulse. To 
enumerate the characteristics of the pulse in the many diseases in 
which it affords us valuable information is beyond the scope of this 
book. The qualities to be expected in the pulse in connection with 
the different diseases of the heart are described in the sections on 



PALPATION AND THE STUDY OF THE PULSE. Ill 

those diseases. Here it will suffice to enumerate some of the con- 
ditions in which vascular tension is usually increased or diminished. 

Low tension is produced by moderate exercise, by warmth {e.g., 
a warm bath), by food. Among pathological conditions we may 
mention especially debilitated states, mental worry, and fever. 

High tension is produced by cold {e.g., cold bathing, malarial 
chills), and by constipation (in some cases). As a rule, the tension 
of the pulse increases with age and is high after the fiftieth year. 
Hysteria and migraine are often associated with increased vascular 
tension. Most frequent among pathological conditions as causes 
of high tension are chronic nephritis and arterio- sclerosis with the 
various diseases in which arterio-sclerosis is a factor (gout, alcohol- 
ism, lead poisoning, diabetes of fat old people, chronic bronchitis 
with emphysema). 

Among valvular heart lesions, aortic and mitral stenosis are 
especially apt to be associated with increased vascular tension. 

Arterial Pressure and the Instruments for Measuring It. 

Within the past few years a number of instruments have come 
into use, the object of which is to tell us with some approach to 
accuracy the lateral pressure in the peripheral arteries. We have 
long attempted to estimate this pressure, by simple digital com- 
pression and palpation, and no doubt these methods in the hands of 
skilled observers will always have a field of usefulness; but it seems 
to me clear that by the instruments about to be described we can 
obtain data in regard to the force of the heart's contractions and the 
tension of the peripheral arteries more accurate and more reliable 
than those furnished by digital examination. This is especially 
true of comparative records, as, for example, if one attempts to 
compare the tension of the pulse to-day with what it was yesterday, 
when one has felt many pulses in the interim. Another objection 
to estimates of pulse pressure based on digital examination results 
from the fact that the size of the artery itself is apt to be a confus- 
ing factor. 

Among the many instruments introduced within the past few 
years we may distinguish (1) those which aim to estimate the 



112 PHYSICAL DIAGNOSIS. 

amount of compression which has to be exerted upon a given artery 
in order to arrest the onward flow of blood in it, and (2) those 
which seek to estimate the amount of pressure in a given artery 
at the moment when its wall makes the widest excursion or oscilla- 
tion. 

Instruments of the first type are said to measure systolic press- 
ure, and those of the second type to measure diastolic pressure. 
Under the first heading I shall describe the Riva-Rocci and Gaert- 
ner instruments. Under the second that of Oliver and that of Hill 
and Barnard. 

1. Gaertner' s Tonometer. — The end of a finger is made blood- 
less by rolling up over it a tight rubber ring. Over the blanched 
finger tip one next applies a pneumatic ring, which can be inflated 
by means of a mbber bulb, while the tension within is meas- 
ured by a manometer connected with it. The manometer may be 
either of the mercury or the spring type. To use the instrument 
we inflate the pneumatic ring until the pressure recorded in the 
manometer is considerably above what we expect in the case dealt 
with. (The tip of the finger all this time remains blanched. ) Next 
we relax the tension within the pneumatic ring, by gradually releas- 
ing the pressure exerted upon the inflation bulb, until the red color 
reappears in the finger tip. Just as the color reappears we note the 
pressure in the manometer. This figure was supposed by Gaertner 
to represent the average or mean pressure in the arteries, but it 
has been very generally conceded by other observers that the figures 
given by this instrument are much nearer to those of systolic press- 
ure, that is, to the pressure during the systole of the left ventricle 
or to the crest of the pulse wave. 

The advantages of the Gaertner instrument are its compactness 
and portability. Its disadvantages are that (in this climate at any 
rate) it is very apt to get out of order, that it is not suited to esti- 
mating pressures in any of the dark-skinned races, and that its 
readings are very much affected by vasomotor influences, such as 
nervousness or cold. If the fingers are cold it may be almost im- 
possible to make a satisfactory record with the instrument. Further, 
the spring manometer, like all instruments of this type, is very apt 



ARTERIAL PRESSURE. 



113 



to get out of order, and if the mercury manometer i's employed the 
instrument loses its only advantage, namely, its compactness. 

2. The Eiva-Eocci Instrument. — This instrument consists essen- 
tially of an inflatable rubber armlet, so arranged that it can be fitted 
closely around the upper arm, a mercury manometer of the ordinary 
type, and an air-pump (see Fig. 70). The air forced from the 




Fig. 70.— Stanton's Modification of the Riva-Rocci Instrument. (By permission from the Uni. 
versity of Pennsylvania Medical Bulletin.) 



pump is distributed into the rubber armlet and into the man- 
ometer at the same time, and experiments have shown that the 
actual pressure in the armlet is practically identical at any given 
time with that in the manometer. To use the instrument we pump 
in air until the radial pulse stops, and at that instant note the 
height of the mercury column. The reading thus obtained is 
8 



114 PHYSICAL DIAGNOSIS. 

taken to represent the systolic or maximum pressure in the brachial 
artery. 

It is true that the air within the rubber armlet has to overcome 
not only the pressure within the radial artery, but the resistance of 
the artery wall and the elasticity of the soft parts around it. The 
former factor has been shown to represent a pressure of not more 
than 2 or 3 mm. Hg, provided the artery walls are normal. If 
arterio-sclerosis is present, it has been estimated by von Basch that 
they may oppose a resistance equivalent to 5 or 6 mm. Hg. The 
amount of error thus introduced, however, appears to be of no im- 
portance, since there are physiological variations of 5 mm. Hg or 
more, occurring from moment to moment, and dependent on changes 
in the force of the heart beat and on the respiratory oscillations of 
pressure. 

The resistance of the soft parts around the artery is a factor of 
considerable importance, provided the compressing armlet is as 
narrow as many of those supplied with Eiva-Eocci instruments. 
But if an armlet of about three and one-quarter inches width is 
used, according to the recommendation cf yon Eecklinghausen and 
Stanton, we find that the pressure is practically the same in a given 
individual whether the armlet is applied round the upper arm, 
round the forearm, or round the thigh. Now if the resistance of 
the tissues of the thigh exerts no greater influence than that of the 
upper arm or forearm, it seems safe to conclude that this factor may 
be neglected as a source of error in comparative measurements with 
arms of different sizes. 

The instrument is a very simple and quick one to use, needing 
very little practice and not more than a minute or a minute and a 
half for a single reading. The chief objection to it is its bulk and 
fragility. 

3. The Instrument of Hill and Barnard. — In essentials this in- 
strument is like the Eiva-Eocci, except that all the connecting tubes 
are rigid, and that in place of the mercury manometer a very deli- 
cate aneroid instrument is employed to record the pressures within 
the armlet (see Fig. 71). The delicacy of this form of manometer 
is so great that with rigid connections it is possible to register the 



ARTERIAL PRESSURE. 



115 



oscillations of the artery wall and to estimate the amount of press- 
ure within the armlet at the time when the arterial oscillations are 
widest ; in other words, when the arteries are slackest. The work 
of Howell and Brush has demonstrated to my satisfaction that the 
pressure at the time of the maximum oscillation corresponds to the 
minimum or diastolic pressure within the arteries. 

The Hill and Barnard instrument, when in good order, seems to 




Fig. 71.— Hill & Barnard's Sphygmometer. 



me on the whole the best among those that are clinically available 
for measuring diastolic pressure. The difficulty of reading it is less 
than with most other instruments designed for this purpose, and 
the only serious drawback to the instrument is the likelihood that 
the manometer will get out of order, a difficulty to which all in- 
struments of this type are very prone. 

4. The Oliver Instrument. — This instrument is intended, like the 
last, for estimating the pressure in the arteries during the period of 
maximum oscillation. This, as I have said, corresponds in my 
opinion to the diastolic and not to the average or mean pressure. 
A small rubber capsule filled with water is placed upon the radial 
artery, and through this the pulsations of the artery, under differ- 
ent pressures, are transmitted directly by a straight rod to a spring 



116 



PHYSICAL DIAGNOSIS. 



manometer, where the oscillations and pressures are recorded in 
mm. Hg (see Fig. 72). The instrument is a very compact and 
simple one, and if it were not constantly getting out of order, would 
be, I think, of considerable value, although it is a difficult instru- 




FiG. 72.— Oliver's Haemodynamometer. 



ment to use. Its readings, however, soon become inaccurate and 
cease to correspond with the mercury column. 

Stanton ( University of JPenn. Med. Bull., February, 1903) has 
succeeded in fitting a Eiva-Rocci instrument with rigid connecting 
tubes, so that with this single instrument he can record both maxi- 
mum and minimum pressures. The maximum or systolic pressure 
he records in the ordinary way. To get the minimum or diastolic 
pressure he clamps off the tube leading to the inflation bulb, and 
then lets out the air little by little until the mercury begins to oscil- 
late in the tube. The oscillations increase in extent up to a maxi- 
mum as the air is steadily let out, and then decrease again until 
they are lost. The reading for diastolic pressure is taken when the 
mercury shows the greatest extent of oscillation in the tube. 



ARTERIAL PRESSURE. 117 



The Use of the Data Obtained by these Instruments. 

The subject is still in its infancy, but in a general way one may 
say that whenever it is important that we should know the strength 
of the heart beat or the tension of the peripheral arteries, these 
instruments are of value. Just which instrument is likely to come 
into permanent use I cannot venture to prophesy, but it seems to 
me likely that the charts of pulse rate will be supplemented before 
long by charts of blood pressure taken at regular intervals as a mat- 
ter of routine. Especially the investigation of diseases of the heart 
and kidney, diseases in which involvement of the suprarenal gland 
is suspected, intracranial hemorrhage or tumor and surgical shock, 
accurate record of blood pressure will be of value. Even the imper- 
fect instruments now in use are capable of yielding us most impor- 
tant information, if applied in comparative measurements upon the 
same patient at different times, so that all the elements of error are 
constant. Thus in the study of drugs like alcohol, digitalis, 
strychnine, ether, chloroform, nitroglycerin, and others which are 
supposed either to raise or to lower blood pressure, these instru- 
ments have, I think, a great field before them. 









CHAPTER VI. 

PEKCUSSIOK 

I. Technique. 

There is no other method of physical examination which needs 
so much practice as percussion, and none that is so seldom thor- 
oughly learned. Many physicians never succeed in acquiring a 
facility in the use of it sufficient to make them rely upon their 
results. Undoubtedly one of the greatest difficulties arises from 
the necessity of being at once active and passive — at once the per- 
cussor and the one who listens to the percussion. Students half 
unconsciously get to treat the percussion as an end in itself, and 
hammer away industriously without realizing that two-thirds of the 
attention must be given to listening, while the percussion itself 
should become semi-automatic. 

It is undoubtedly an advantage to possess a musical ear, but this 
is by no means a necessity. Some of the most accurate percussors 
that I know possess absolutely no musical ear — no ear, that is, for 
pitch — and form their judgments in percussing upon the quality or 
intensity of the note, and upon the sense of resistance. 

In this country practically all percussion is done with the fin- 
gers ; in Germany instruments are still used to a considerable ex- 
tent. 

{a) Mediate and Immediate Percussion. 

Percussion may be either " mediate " or " immediate, " the lat- 
ter term referring to blows struck directly upon the chest with the 
flat of the hand, or upon the clavicles with the tip of the second 
finger. 



PERCUSSION. 



119 



(b) Methods. 

Mediate percussion (which is used ninety-nine hundredths of 
the time) is performed as follows : 

The patient should either lie down or sit with his back against 
some support. The reason of this is that for good percussion one 



fig 




Position of the Hands When Percussing the Right Apex. 



needs to press very firmly with the middle finger of the left hand 
upon the surface of the chest, so firmly that if the patient is sitting 
upon a stool without support for his back, it will need considerable 
exertion upon his part to avoid losing his balance. 



120 



PHYSICAL DIAGNOSIS. 



In percussing the front of the chest it is important to have the 
patient sitting or lying in a symmetrical position — that is, without 
any twist or tilting to one side. His head should point straight 
forward and his muscles must be thoroughly relaxed. Many pa- 
tients, when stripped for examination, swell out their chests and 




n 



4 



Fig. 74.— Position of the Hands When Percussing the Left Apex. 

sit up with a military erectness. The muscular tension thus pro- 
duced modifies the percussion note and causes an embarrassing 
multitude of muscle sounds which greatly disturb auscultation. 

Having placed the patient in an easy and symmetrical position, 
our percussion should proceed according to the following rules : 

(1) Always press as firmly as possible upon the surface of the 



PERCUSSION. 



121 



chest with the second finger of the left hand ' on the dorsum of 
which the blow is to be struck. Raise the other fingers of the left 
hand from the chest so as not to interfere with its vibrations. 

(2) Strike a quick, perpendicular, rebounding blow with the tip 
of the second finger 2 of the right hand upon the second finger of the 
left just behind the nail, imitating as far as possible with the right 
hand the action of a piano-hammer. The quicker the percussing 




Fig. 75.— The Right Way to Percuss— i. e., From the Wrist. 

finger gets away again after striking, the clearer will be the note 
obtained. 

(3) Let all the blows struck in any one part of the chest be 
uniform in force. 



1 Left-handed percussors will, of course, keep the right hand upon the 
chest and strike with the left. 

2 When percussing the right apex I prefer to strike upon the thumb (see 
Figs. 73 and 74) as it is almost impossible when standing directly in front 
of the patient to fit any of the fingers comfortably into the right supraclavicular 
fossa. 



122 



PHYSICAL DIAGNOSIS. 



(4) Strike from the wrist and not from the elbow (see Figs. 75 
and 76). The wrist must be held perfectly loose. 

(5) Keep the percussing finger bent at a right angle as in Fig. 
77. 

The force to be used in percussion depends upon the purpose 




Fig. 76.— The Wrong Way to Percuss— i. e., From the Elbow. 

for which the percussion is used — that is, upon what organ we are 
percussing — and also upon the thickness of the muscles covering 
that part of the chest. For example, it is necessary to percuss 
very strongly when examining the back of a muscular man, where 
an inch or two of muscle intervenes between the finger on which 



PERCUSSION. 



123 



we strike and the lung from which we desire to elicit a sound. 
Over the front of the chest and in the axillae the muscular covering 
is much thinner, and hence a lighter blow suffices. In children or 
emaciated patients, or in any case in which the muscular develop- 
ment is slight, percussion should be as light as is sufficient to elicit a 
clear sound. Heavy percussion is sometimes necessary but always 
unsatisfactory, in that the sound which it elicits comes from a rela- 
tively large area of the chest and does not therefore give us infor- 








Fig. 



-Proper Position of the Right Hand During Percussion. 



mation about the condition of any sharply localized area. If a car- 
penter, in tapping the wall to find the position of the studs, strikes 
too hard, he will fail to find the beam, because the blow delivered 
over the spot behind which the beam is situated is so forcible as to 
bring out the resonance of the hollow parts around. It is the same 
with medical percussion. Heavy percussion is always inaccurate. 1 
It may be necessary where the muscles are very thick, but its value 

1 See also below, page 136, the lung reflex. 



124 



PHYSICAL DIAGNOSIS. 



is then proportionately diminished. On the other hand, it is pos- 
sible to strike so lightly that no recognizable sound is elicited at 
all. The best percussion, therefore, is that which is just forcible 
enough to elicit a clear sound without setting a large area of chest 
wall in vibration. 

The position of the patient above described applies to percus- 
sion of the front. When we desire to percuss the back, it is im- 




Fig. 78.— Proper Position of the Patient During Percussion of the Back. 



portant to get the scapulse out of the way as far as possible, since 
we cannot get an accurate idea of sounds transmitted through them. 
To accomplish this, we put the patient in the position shown in 
Fig. 78, the arms crossed upon the chest and each hand upon the 
opposite shoulder. The patient should be made to bend forward ; 
otherwise the left hand of the percussor will be uncomfortably bent 
backward and his attention thereby distracted (see Fig. 79). 

When the axillae are to be percussed, the patient should put the 
hands upon the top of the head. 



PERCUSSION. 



125 



(b) Auscultatory Percussion. 

If while percussing one auscults at the same time, letting the 
chest piece of the stethoscope rest upon the chest, or getting the 
patient or an assistant to hold it there, the sounds produced by 
percussion are greatly intensified, and changes in their volume, 
pitch, or quality are very readily appreciated. The blows must be 



fig. 




Wrong Position for Percussing the Back. The patient should be bent forward. 



very lightly struck, either upon the chest itself or upon the finger 
used as a pleximeter in the ordinary way. Some observers use a 
short stroking or scratching touch upon the chest itself without 
employing any pleximeter. 

This method is used especially in attempting to map out the 
borders of the heart and in marking the outlines of the stomach. 
In the hands of skilled observers it often yields valuable results, 



126 



PHYSICAL DIAGNOSIS. 



but one source of error must be especially guarded against. The 
line along which we percuss, when approaching an organ whose bor- 
ders we desire to mark out, must neither approach the chest piece of 
the stethoscope nor recede from it. In other words, the line along 
which we percuss must always describe a segment of a circle whose 
centre is the chest piece of the stethoscope (see Fig. 80). If we 
percuss, as we ordinarily do, in straight lines toward or away from 
the border of an organ, our results are wholly unreliable since 
every straight line must bring the point percussed either closer to 



Percussion arc. 



Chest-piece of 
Stethoscope. 




Fig. 80.— Auscultatory Percussion, Showing the Arc along which such Percussion should be 

made. 



the stethoscope or farther from it, and the intensity and quality 
of the sounds conducted through the instrument to our ears vary 
directly with its distance from the point percussed. 

It will be readily seen that the usefulness of auscultatory per- 
cussion is limited by this source of error, and that considerable 
practice is necessary before one can get the best results from this 
method. Nevertheless it has, I believe, a place, though not a very 
important one, among serviceable methods of physical examination. 



PERCUSSION. 



127 



(c) Palpatory Percussion. 

Some German observers use a method of percussion in which 
attention is fixed directly or primarily on the amount of resistance 
offered by the tissues over which percussion is made. Even in or- 
dinary percussion the amount of resistance is always noted by 
experienced percussors, but the element in sound is usually the 
main object of attention. Palpatory percussion is rather a series 
of short pushes against various points on the chest wall, but some 



Normal dulness 
of the right apex. 



Liver dulness. < 



Liver flatness. 




Deep cardiac 
dulness. 



Superficial cardiac 
dulness. 



Traube's semilu- 
nar tympanitic 
space. 



Fig. 81,— Percussion Outlines in the Normal Chest. 

sound is elicited and probably enters into the rather complex jud< 
ment which follows. 

In this country palpatory percussion is but little employed. 



II. Percussion Eesonance of the Normal Chest. 

The note obtained by percussing the normal chest varies a great 
deal in different areas. In Fig. 81, the parts shaded darkest are 
those that normally give least sound when percussed in the manner 
described above, while from the lightest areas the loudest and clear- 
est sound may be elicited. 



128 



PHYSICAL DIAGNOSIS. 



-- Lower lobe. 



~. Splenic area. 



(a) The sound elicited in the latter areas is known as normal or 
"vesicular" resonance, and is due to the presence of a normal 
amount of air in the vesicles of the lung underneath. If this air- 
containing lung is replaced by a fluid or solid medium, as in pleu- 
ritic effusion or pneumonia, it is much more difficult to elicit a 
sound, and such sound as is produced is 
short, high pitched, and has a feeble carry- 
ing power when compared with the sound 

elicited from the normal lung. This 
^--- Upper lobe. ° 

short, feeble, high-pitched sound is 
known technically as a "dull" or 
"flat" sound, flatness designating 
the extreme of the qualities that 
characterize dulness. Over the 
parts shaded dark in Fig. 81, we 
normally get a dull or flat tone, the darkest 
portions being flat and the others dull. 
The heavy shadow on the right corresponds 
to the position occupied by the liver, or 
rather by that part of it which is in imme- 
diate contact with the chest wall. The up- 
per portion of the liver is overlapped by the 
right lung (see Fig. 81), and hence at this 
point we get a certain amount of resonance 
on percussion, although the tone is not so 
clear as that to be obtained higher up. Be- 
low the sixth rib we find true flatness near 
the sternum and for a few niches to the right 
of this point. As we go toward the axilla, 
resonance slopes down, as is seen in Fig. 82. In 




Fig. 82. —Position of the Left 
Lung in the Axilla. 



the line of luns 



the back resonance extends to the ninth or tenth ribs. 



Normal Dull Areas. 

(b) On the left side, the main dull area corresponds to the heart, 
which at this point approaches the chest wall, and over the por- 
tion shaded darkest is uncovered by the lung. The part here 



PERCUSSION. 129 

lightly shaded corresponds to that portion of the heart which is 
overlapped by the margin of the right and left lungs. 

Over the portion of the heart not overlapped by the lung (see 
Fig. 81, p. 127) the percussion note is nearly flat to light percus- 
sion, and very dull even when strongly percussed. This little 
quadrangular area is known as the "superficial cardiac space," and 
the dulness corresponding to it is referred to as the "superficial" 
cardiac dulness, while the dulness corresponding to the outlines of 
the heart itself beneath the overlapping lung margins is called the 
"deep" cardiac dulness. 

When the heart becomes enlarged, both of these areas, the deep 
and the superficial, are enlarged, the former corresponding to the 
increased size of the heart itself, while the superficial cardiac space 
is extended because the margins of the lungs are pushed aside and 
a larger piece of the heart wall comes in contact with the chest 
wall. Accordingly, either the superficial or the deep dulness may 
be mapped out as a means of estimating the size of the heart. 
Each method has its advantages and its advocates. The superficial 
dulness is easier to map out, but varies not only with the size of the 
heart, but with the degree to which the lungs are distended with 
air, or adherent to the pericardium or chest wall. What we are 
percussing is in fact the borders of the lungs at this point. 

On the other hand, the deep cardiac dulness is much more satis- 
factory as a means of estimating the size of the heart but much 
more difficult to map out. It needs a trained ear and long practice 
to percuss out correctly the borders of the heart itself, especially 
the right and the upper borders, since here we have to percuss 
over the sternum where differences of resonance are very deceptive 
and difficult to perceive. 

It is a disputed point whether light or forcible percussion should 
be used when we attempt to map out the deep cardiac dulness. 
Heavy percussion is believed by its advocates to penetrate through 
the overlapping lung margins and bring out the note corresponding 
to the heart beneath, a note which, they say, is missed altogether 
by light percussion. On the other hand, those who employ light 
percussion contend that heavy percussion sets in vibration so large 
9 






130 PHYSICAL DIAGNOSIS. 

an area of lung superficially that fine distinctions of note are made 
impossible (see above, p. 123). 

Good observers are to be found on each side of this question, 
and I have no doubt that either method works well in skilled 
hands. Personally I have found light percussion preferable. 

Whatever method we use we must percuss successive points 
along a line running at right angles to the border of the organ 
which we wish to outline until a change of note is perceived. 
Thus, if we wish to percuss out the upper border of the liver, we 
strike successive points along a line running parallel to the ster- 
num and about an inch to the right of it. 1 When a change of note 
is perceived, the point should be marked with a skin pencil ; then 
we percuss along a line parallel to the first one, and perhaps an 
inch farther out, and again mark with a dot the point at which the 
note first changes. A line connecting the points so marked upon 
the skin represents the border of the organ to be outlined. 

If now we look at the upper part of the chest in Fig. 81, we 
notice at once that the two sides are not shaded alike : the left apex 
is distinctly lighter colored than the right. This is a very impor- 
tant point and one not sufficiently appreciated by students. The 
apex of the normal right lung is distinctly less resonant than the 
apex of the left in a corresponding position. 

In percussing at the bottom of the left axilla, we come upon a 
small oval area of dulness corresponding to that outlined in Fig. 82. 
This is the area of splenic dulness, so called, and corresponds to 
that portion of the spleen which is in contact with the chest wall. 
This dull area is to be made out only in case the stomach and colon 
are not overdistended with air. When these organs are full of gas 
as is not infrequently the case, there is no area of splenic dulness 
and the whole region gives forth, when percussed, a note of a qual- 
ity next to be described, namely, "tympanitic." 

(c) Tympanitic resonance is that obtained over a hollow body, 
like the stomach when moderately distended with air. 2 It is usu- 

1 Or we may reverse the procedure ; percuss first over the liver and then 
work toward the lung above until the note becomes more resonant. 

2 Extreme distention here, as in a snare drum, is associated with a dull 
percussion note (see below, p. 332). 



PERCUSSION. 131 

ally of a higher pitch than the resonance to be obtained over the 
normal lung, and may be elicited by percussion lighter than that 
needed to bring out the lung resonance. It differs also from the 
vesicular or pulmonary resonance in quality, in a way easy to appre- 
ciate but difficult to describe. Tympanitic resonance is usually to 
be heard when one percusses over the front of the left chest near 
the ensiform cartilage and for a few inches to the left of this point 
over an area corresponding with that of the stomach more or less 
distended with air. This tympanitic area, known as " Traube's 
semilunar space" varies a great deal in size according to the contents 
of the stomach. It is bounded on the right by the liver flatness, 
above by the pulmonary resonance, on the left by the splenic dul- 
ness, and below by the resonance of the intestine, which is also 
tympanitic, although its pitch is different owing to the different 
size and shape of the intestine. 

(The right axilla shows normal lung resonance down to the 
point at which the liver flatness begins, as shown in Fig. 81.) 

In the back, when the scapulae are drawn forward, as shown in 
Fig. 78, page 124, percussion elicits a clear vesicular resonance from 
top to bottom on each side, although the top of the right lung is al- 
ways slightly less resonant than the top of the left, and sometimes the 
bottom of the right lung is slightly less resonant than the corre- 
sponding portion of the left, on account of the presence of the liver 
on the right. 

It should be remembered, however, that in the majority of cases 
the resonance throughout the back is distinctly less than that ob- 
tained over the front, on account of the greater thickness of the 
back muscles. Yet in children or emaciated persons, or where the 
muscular development is slight, there may be as much resonance 
behind as in front. 

Importance of Percussing Symmetrical Points. — Since we depend 
for our standard of resonance upon comparison with a similar spot 
on the outside of the chest, it is all-important that in making such 
comparisons we should percuss symmetrical points, and not, for 
example, compare the resonance over the third rib in the right front 
with that over the third interspace on the left, since more resonance 
can always be elicited over an interspace than over a rib. This 



132 PHYSICAL DIAGNOSIS. 

comparison of symmetrical points, however, is interfered with by 
the presence of the heart on one side and the liver on the other, as 
well as by the fact that the apex of the right lung is normally less 
resonant than that of the left A resonance which would be patho- 
logically feeble if obtained over the left top may be normal over the 
right Where both sides are abnormal, as in bilateral disease of 
the lung, or where fluid accumulates in both pleural cavities, we 
have to make the best comparison we can between the sound in the 
given case and an ideal standard carried in the mind. 

It must always be remembered that the amount of resonance 
obtained at any point by percussion depends upon how hard one 
strikes, as well as upon the conditions obtaining within the chest. 
A powerful blow over a diseased lung may bring out more reso- 
nance than a lighter blow over a normal lung. To strike with per- 
fect fairness and with equal force upon each side can be learned only 
by considerable practice. Furthermore, the distance from the ear 
to each of the two points, the resonance of which we are compar- 
ing, must be the same — that is, we must stand squarely in front or 
squarely behind the patient, otherwise the note coming from the 
part farther from the ear will sound duller than that coming from 
the nearer side. 

The normal resonance of the different parts of the chest can be 
considerably modified by the position of the patient, by deep breath- 
ing, by muscular exertion, and by other less important conditions. 
If, for example, the patient lies upon the left side, the heart swiugs 
out toward the left axilla and its dulness is extended in the same 
direction. Deep inspiration pushes forward the margins of the 
lungs so that they encroach upon and reduce the area of the heart 
dulness and liver dulness. After muscular exertion the lungs be- 
come more than ordinarily voluminous, owing to the temporary dis- 
tention brought about by the unusual amount of work thrown upon 
them. 

The area of cardiac dulness is increased in any condition involv- 
ing insufficient lung expansion. Thus, in children, in debility, 
chlorosis, or fevers, the space occupied by the lungs is relatively 
small and the dull areas corresponding to the heart and liver are 



PERCUSSION. 133 

proportionately enlarged. In old age, on the other hand, when the 
lungs have lost part of their elasticity and sag down over the heart 
and liver, the percussion dulness of these organs is reduced. 

Conditions Modifying the Percussion Note in Health. — The de- 
velopment of muscle or fat as well as the thickness of the chest 
wall will influence greatly the amount of resonance to be obtained 
by percussion. Indeed, we see now and then an individual in no 
part of whose chest can any clear percussion tone be elicited. In 
women, the amount of development of the breasts has also great 
influence upon the percussion note, In children, the note is gener- 
ally clearer, and only the lightest percussion is to be used on ac- 
count of the thinness of the chest- wall. In old people whose lungs 
are almost always more or less emphysematous, a shade of tym- 
panitic quality is added to the normal vesicular resonance. The 
distention of the colon with gas may obliterate the liver dulness by 
rotating that organ so that only its edge is in contact with the chest 
wall, and if there is wind in the stomach, a variable amount of 
tympany is heard on percussing the lower left front and axilla or 
even in the left back. 

If a patient is examined while lying on the side the amount of 
resonance over the lung corresponding to the side on which he 
lies is usually less than that of the side which is uppermost, because 
there is more air in the latter. Whatever the patient's position, 
the amount of resonance is also greater at the end of inspiration 
than at the end of expiration, for the reason just given. As the 
lungs expand with full inspiration, their borders move so as to 
cover a larger portion of the organs which they normally overlap. 
Portions of the chest which at the end of expiration are dull or 
flat, owing to the close juxtaposition of the heart, liver, or spleen, 
become resonant at the end of inspiration For example, the lower 
margin of the right lung moves down during inspiration so as to 
cover a considerably larger portion of the liver. 

Percussion as a Means of Ascertaining the Movability of the Lung 
Borders. — It is often of great importance to determine not merely 
the position of the resting lung but its power to expand freely. 
This can be ascertained by percussion in the following way : The 



134 PHYSICAL DIAGNOSIS. 

lower border of the lung resonance, say in the axilla, is carefully 
marked out. Then percussion is made over a point just below the 
level of the resting lung and at the same time the patient is directed 
to inspire deeply If the lung expands and its border moves down, 
the percussion note will change suddenly from dull to resonant 
during the inspiration. An excursion of two or three inches can 
often be demonstrated by this method, which is especially impor- 
tant for the anterior and posterior margins of the lung. In the 
axilla Litten's phrenic shadow will give us the same information. 

The mobility of the borders of the lung, as determined by this 
method, is of considerable clinical importance, for an absence of 
such mobility may indicate pleuritic adhesions. Its amount de- 
pends upon various conditions and varies much in different indi- 
viduals, but complete absence of mobility is always pathological. 

(d) Cracked-Pot Resonance 

When percussing the chest of a crying child, we sometimes 
notice that the sound elicited has a peculiar " chinking " quality, 
like that produced by striking one coin with another, but more 
muffled. The sound may be more closely imitated, and the mode 
of its production illustrated, by clasping the hands palm to palm 
so as to enclose an air space which communicates with the outer air 
through a chink left open, and then striking the back of the under 
hand against the knee By the blow, air is forced out through the 
chink with a sound like that of metallic coins struck together. 

In disease, the cracked-pot sound is usually produced over a 
pulmonary cavity (as in advanced phthisis) from which the air is 
suddenly and forcibly expelled by the percussion stroke. 

It is much easier to hear this peculiar sound if, while percuss- 
ing, one listens with a stethoscope at the patient's open mouth. 
The patient himself holds the chest piece of the instrument just in 
front of his open mouth, leaving the auscultator's hands free for 
percussing. 



PERCUSSION. 135 

(e) Amphoric Resonance. 

A low-pitched hollow sound approximating in quality to tym* 
panitic resonance, and sometimes obtained over pulmonary cavities 
or over pneumothorax, has received the name of amphoric reso- 
nance- It may be imitated by percussing the trachea or the cheek 
when moderately distended with air. 

Summary 

The varieties of resonance to be obtained by percussing the nor- 
mal thorax are : 

(1) Vesicular resonance, to be obtained over normal lung tissue. 

(2) Tympanitic resonance, to be obtained in Traube's semilunar 
space 

(3) Diminished resonance or dulness, such as is present over the 
scapulae, and 

(4) Absence of resonance or -flatness, such as is discovered when 
we percuss over the lowest ribs in the right front 

(5) Cracked-pot resonance, sometimes obtainable over the chest 
of a crying child. 

(6) Amphoric resonance, obtainable over the trachea. 

Any of these sounds may denote disease if obtained in portions 
of the chest where they are not normally found. Each has its 
pjlace, and becomes pathological if found elsewhere. Tympanitic reso- 
nance is normal at the bottom of the left front and axilla, but not 
elsewhere. Dulness or flatness is normal over the areas corre- 
sponding to the heart, liver, and spleen, and over the scapulse, but 
not elsewhere unless the muscular covering of the chest is enor- 
mously thick. Vesicular resonance is normal over the areas corre- 
sponding to the lungs, but becomes evidence of disease if found 
over the cardiac or hepatic areas. 

Cracked-pot resonance may be normal if produced while per- 
cussing the chest of a child, but under all other conditions, so far 
as is known, denotes disease. 

Amphoric resonance always means disease, usually pulmonary 
cavity or pneumothorax, if found elsewhere than over the trachea. 



136 PHYSICAL DIAGNOSIS. 



(f) The Lung Reflex. 

It must also be remembered, when percussing, that in some cases 
every forcible percussion blow increases the resonance to be ob- 
tained by subsequent blows. Any one who has demonstrated an 
area of percussion dulness to many students in succession must 
have noticed occasionally that the more we percuss the dull area, 
the more resonant it becomes, so that to those who last listen to 
the demonstration the difference which we wish to bring out is much 
less obvious than to those who heard the earliest percussion strokes. 
Abrams has referred to this fact under the name of the "lung re- 
flex," believing, partly on the evidence of fluoroscopic examination, 
that if an irritant such as cold or mustard is applied to any part of 
the skin covering the thorax, the lung expands so that a localized 
temporary emphysema is produced in response to the irritation. 
Apparently percussion has a similar effect. 

III. Sexse of Resistance. 

While percussing the chest we must be on the lookout not only 
for changes in resonance, but for variations in the amount of resist- 
ance felt underneath the finger. Normally the elasticity of the 
chest walls over the upper fronts is considerably greater and the 
sense of resistance considerably less than that felt over the liver. 
In the axillae and over those portions of the back not covered by 
the scapulae, we feel in normal chests an elastic resistance when 
percussing which is in contrast with the dead, woodeny feeling 
which is communicated to the finger when the air-containing lung 
is replaced by fluid or solid contents (pleuritic effusion, pneu- 
monia, phthisis, etc.). In some physicians this sense of resistance 
is very highly developed and as much information is obtained 
thereby as through the sounds elicited. As a rule, however, it is 
only by long practice that the sense of resistance is cultivated to a 
point where it becomes of distinct use in diagnosis. 



CHAPTER VII. 

AUSCULTATION. 

Auscultation may be practised by placing one's ear directly 
against the patient's chest (immediate auscultation) or with the 
help of a stethoscope (mediate auscultation). 

Each method has its place. Immediate auscultation is said to 
have advantages similar to those of the low power of the micro- 
scope, in that it gives us a general idea of the condition of a rela- 
tively large area of tissue, while the stethoscope may be used, like 
the oil immersion lens, to bring out details at one or another point. 

On the other hand, I have heard it said by E. G. Janeway and 
other accomplished diagnosticians that the unaided ear can perceive 
sounds conducted from the interior of the lung — sounds quite inau- 
dible with any stethoscope— and that in this way deepseated areas 
of solidification may be recognized. 

Immediate auscultation may be objected to 

(a) On grounds of delicacy (when examining persons of the 
opposite sex). 

(b) On grounds of cleanliness (although the chest may be cov- 
ered with a towel so as to protect the auscultator to a certain 
extent). 

(c) Because we cannot conveniently reach the supraclavicular 
or the upper axillary regions in this way. 

(d) Because it is difficult to localize the different valvular areas 
and the sites of cardiac murmurs if immediate auscultation is em- 
ployed. 

On account of the latter objection the great majority of observ- 
ers now use the stethoscope to examine the heart. For the lungs, 
both methods are employed by most experienced auscultators. 



138 PHYSICAL DIAGNOSIS. 

(Personally, I have never yet learned to hear anything with my 
nnaidecl ear which I could not hear better with a stethoscope, and 
the Bowles stethoscope seems to me to reach as large an area and 
as deep as the unaided ear. Nevertheless the weight of competent 
opinion is against me and greater experience will doubtless show 
me my mistake.) 

While learning the use of immediate auscultation it is best to 
close with the fingers the ear which is not in contact with the chest. 
With practice one comes. to disregard outer noises and does not 
need to stop the ear. 

Mediate Auscultation. 

1. Selection of a Stethoscope. 

(1) It is as rash for any one to select a stethoscope without first 
trying the fit of the ear pieces in his ears as it would be to buy a 
new hat without trying it on. What suits A. very well is quite im- 
possible for B. It is true that one can get used to almost any 
stethoscope as one can to almost any hat, but it is not necessary to 
do so. The ear pieces of the ordinary stethoscope are often too 
small and rarely too large. In case of doubt, therefore, it is better 
to err upon the side of getting a stethoscope with too large rather 
than too small ends. 

(2) The binaural stethoscope, which is now almost exclusively 
used in this country, maintains its position in the ears of the aus- 
cultator either through the pressure of a rubber strap stretched 
around the metal tubes leading to the ears, or by means of a steel 
spring connecting the tubes. Either variety is usually satisfactory, 
but I prefer a stethoscope made with a steel spring (see Fig. 83) 
because such a spring is far less likely to break or lose its elasticity 
than a rubber strap. A rubber strap can always be added if this 
is desirable. It is important to pick out an instrument possessing 
a spring not strong enough to cause pain in the external meatus of 
the ear and yet strong enough to hold the ear pieces firmly in place. 
Persons with narrow heads need a much more powerful spring or 
strap than would be convenient for persons with wide heads. 



AUSCULTATION. 



139 



(3) The rubber tubing used to join the metallic tubes to the 
chest piece of the instrument should be as flexible as possible (see 
Fig. 83). Stiff tubing (see 
Fig. 84) makes it necessary 
for the auscultator to move 
his head and body from 
place to place as the exam- 
ination of the chest pro- 
gresses, while if flexible 
tubing is used the head need 
seldom be moved and a great 
deal of time and fatigue is 
thus saved. Stiff stetho- 
scopes are especially incon- 
venient when examining the 
axilla. 

(4) Jointed stethoscopes 
which fold up or take apart 
should be scrupulously 
avoided. They are a delu- 
sion and a snare, apt to 
come apart at critical mo- 
ments, and to snap and creak 
at the joints when in use, 
sometimes producing in this way sounds which 
may be easily mistaken for rales. Such an in- 
strument is no more portable nor compact than 
the ordinary form with flexible tubes. It has, 
therefore, no advantages over stethoscopes made 
in one piece and possesses disadvantages which 
are peculiarly annoying. 

(5) The Chest Piece. — The majority of the 

stethoscopes now in use have a chest piece of 

hard-rubber or wood with a diameter of about seven-eighths of an 

inch. Chest pieces of larger diameter than this are to be avoided 

as they are very difficult to maintain in close apposition with thin 




Fig. 84. — C a m m a n 
Stethoscope With Stiff 
Tubing and Rubber 
Strap. 



Fig. 83. — Stethoscope 
Fitted With Long 
Flexible Tubes, Espe- 
cially Useful When 
Examining Children. 



140 



PHYSICAL DIAGNOSIS. 



chests. To avoid this difficulty the chest piece is sometimes made 
of soft-rubber or its diameter still further reduced. 

(6) The Bowles Stethoscojw. — fiee Figs. 85 and 86). Within 
the last year there has been introduced an instrument which, for 
most purposes, seems to me far superior to any other form of stetho- 
scope with which I am acquainted. Its pe- 
culiarity is the chest piece, 
which consists of a very shal- 
low steel cup (see Fig. 87) 
over the mouth of which a 
thin metal plate or a bit 
of pigskin is fastened. The 
metal or pigskin diaphragm 
serves simply to prevent the 
tissues of the chest from pro- 
jecting into the shallow cup 
of the chest piece when the 
latter is pressed against the 
chest, and does not in any 
other way contribute to the 
sounds which we hear with 
the instrument. This is 
proved by the fact that we 
can hear as well even when 
the diaphragm is cracked 
across in several directions. 
With this instrument al- 
most all sounds produced 
within the chest can be heard 

Fig. 85.-Bowies' stetho- mucnmore distinctly than in 
scope. Front view, any other variety of stetho- 
scope. Cardiac murmurs 
which are inaudible with any other stetho- 
scope may be distinctly heard with this. Espe- 
cially is this true of low-pitched murmurs 

due to aortic regurgitation. Yet it is useful for examination 
not merely of the heart, but of the lungs as well, For any one 





Fig. 86.— Combination 
Bowies' Stethoscope. 



AUSCULTATION. 141 

who has difficulty in hearing the ordinary cardiac or respiratory 
sounds, or for one who is partially deaf, the instrument is invalu- 
able. As the metal rim of the chest is apt to get unpleasantly 
cold, it is best to cover it with a bit of rubber or kid. This saves 
the patient some discomfort and also tends to prevent the instru- 
ment from slipping on the skin. The flat chest piece makes the 
instrument very useful in listening to the posterior portions of the 
lungs in cases of pneumonia in which the patient is too sick to be 
turned over or to sit up. Without moving the patient at all we can 




Fig. 87.— Chest Piece of Bowies' stethoscope. On the right the shallow cup communicating 
with the ear tubes. On the left the diaphragm which covers the cup, and the ring which 
holds it in place. 

work the chest piece in under the back of the patient by pressing 
down the bed-clothes, and in this way can listen to any part of 
the chest without moving the patient. A further advantage of 
the instrument is that it enables us to gain an approximately ac- 
curate idea of the heart sounds without undressing the patient. Ee- 
spiratory sounds cannot well be listened to through the clothes, 
as the rubbing of the latter may simulate rales. 

There are two purposes for which I have found the Bowles 
stethoscope inferior to the ordinary stethoscope : 

(1) For listening over the apex of the lung for fine rales, e.g., in 
incipient phthisis. 

(2) For listening for superficial sounds, such as a friction rub or 



144 



PHYSICAL DIAGNOSIS. 



tion or concentration upon those sounds which we know to be of 
importance. 

Among the sounds which we must learn to disregard are the 
following : 

(1) Noises produced in the room or its immediate neighborhood, 
but not connected with the patient himself. It is, of course, easier 




Fig. 90.— Bowies' Multiple Stethoscope in Use. Twelve students listening at once. 

to listen in a perfectly quiet room where there are no external 
noises which need to be excluded from attention, but as the greater 
part of the student's work must be done in more or less noisy 
places, it is for the beginner a practial necessity to learn to with- 
draw his attention from the various sounds which reach his ear 
from the street, from other parts of the building, or from the room 



AUSCULTATION. 145 

in which he is working. This is at first no easy matter, bnt can 
be accomplished with practice. 

(2) When the power to disregard external noises has been ac- 
quired, a still further selection mnst be made among the sounds 
which come to the ear through the tubes of the stethoscope. Noises 
produced by friction of the chest piece of the stethoscope npon the 
skin are especially deceptive and may closely simulate a pleural or 
pericardial friction sound. It is well for the student to experiment 
upon the nature and extent of such " skin rubs " by deliberately 
moving the chest piece of the stethoscope upon the skin and listen- 
ing to the sounds so produced. Mistakes can be avoided in the 
majority of cases by holding the chest piece of the stethoscope very 
firmly against the chest. This can be easily done when the patient 
is in the recumbent position, but when the patient is sitting up it 
may be necessary to press so hard with the chest piece of the 
stethoscope as to throw the patient off his balance unless he is in 
some way supported ; accordingly, it is my practice in many cases 
to put the left arm around and behind the patient so as to form a 
support, against which he can lean when the chest piece of the 
stethoscope is pressed strongly against his chest. When listening 
to the back of the chest, the manoeuvre is reversed. If the skin 
is very dry, the ribs are very prominent, or the chest is thickly 
covered with hair, it may be impossible to prevent the occur- 
rence of adventitious sounds due to friction of the chest piece 
upon the chest, no matter how firmly the instrument is held. In 
case of doubt, and in any case in which a diagnosis of pleural or 
pericardial friction is in question, the surface of the chest, at the 
point where we desire to listen, should be moistened and any hair 
that may be present thoroughly wetted with a sponge, so that it 
will lie flat upon the chest. Otherwise the friction of the hair 
under the chest piece of the stethoscope may simulate crepitant 
rales as closely as " skin rubs " simulate pleural friction. 

(3) The friction of the fingers of the auscultator upon the chest 
piece or on some other part of the stethoscope frequently gives rise 
to sounds closely resembling rales of one or another description. 
The nature of these sounds can be easily learned by intentionally 
moving the fingers upon the stethoscope. They are to be avoided 

10 



146 PHYSICAL DIAGNOSIS. 

by grasping the instrument as firmly as possible, and by touching it 
with as few fingers as will suffice to hold it close against the chest. 

(4) Noises produced by a shifting of the parts of the stetho- 
scope upon each other are especially frequent in stethoscopes made 
in several pieces and jointed together A variety of snapping and 
cracking sounds, not at all unlike certain varieties of rales, may 
thus be produced, and if we are not upon our guard, may lead to 
errors in diagnosis. Stethoscopes which have no hinges and which 
do not come apart are far less likely to trouble us in this way. 

(5) When a rubber band is used to press the ear pieces more 
firmly into the ears, a very peculiar sound may be produced by the 
breathing of the auscultator as it strikes upon the rubber strap. It 
is a loud musical note, and may be confused with coarse, dry rales. 

When one has learned to recognize and to disregard the noises 
produced in the ways above indicated, there is still one set of 
sounds which are very frequently heard, yet which have no signifi- 
cance for physical diagnosis, and must therefore be disregarded ; I 
refer to 

B. Muscle Sounds. 

Patients who hold themselves very erect while being exam- 
ined, or who for any reason contract the muscles of that portion of 
the chest over which we are listening, produce in these muscles a 
very peculiar and characteristic set of sounds. The contraction of 
any muscle in the body produces sounds similar in quality to those 
heard over the chest, but of less intensity. 

Those who have the faculty of contracting the tensor tympani 
muscle at will can at any time listen to a typical muscle sound. 
Or close both ears with the fingers and strongly contract the mas- 
seter muscle, with the teeth clenched. A high-pitched muscle 
sound will be heard. 

It is well also to have a patient contract one of the pectorals 
and then listen to the sound thus produced. In some cases a con- 
tinuous, low-pitched roar or drumming is all that we hear ; in other 
cases we hear nothing but the breath sounds during expiration, 
while during inspiration the breath sound is obscured by a series of 



AUSCULTATION. 147 

short, dull, rumbling sounds, following each other at the rate of 
from five to ten in a second. Occasionally the sound is like the 
puffing of the engine attached to a pile-driver, or like a stream of 
water falling upon a sheet of metal just slowly enough to be sepa- 
rated into drops and heard at a considerable distance. As already 
mentioned, we are especially apt to hear these muscle sounds dur- 
ing forced inspiration, owing to the contraction of voluntary mus- 
cles during that portion of the respiratory act. They are most 
often heard over the upper portion of the chest (over the pectorals 
hi front and over the trapezius behind), but in some persons no 
part of the chest is free from them. It is a curious fact that we 
are not always able to detect by sight or touch the muscular con- 
tractions which give rise to these sounds, and the patient himself 
may be wholly unaware of them. Under such circumstances they 
are not infrequently mistaken for rales, and I am inclined to think 
that many of the sounds recorded as "crumpling," "obscure," 
"muffled," "distant," or "indeterminate" rales are in reality due 
to muscular contractions. The adjectives "muffled" and "distant " 
give us an inkling as to the qualities which distinguish muscular 
sounds from rales. Kales are more clean cut, have a more distinct 
beginning and end, seem nearer to the ear, and possess more of a 
crackling or bubbling quality than muscle sounds. 

I have made no attempt exhaustively to describe all the sounds 
due to muscular contractions and conducted to the ear by the steth- 
oscope, but have intended simply to call attention to the importance 
of studying them carefully. 

C. Other Sources of Error. 

Another source of confusion, which for beginners is very trouble- 
some, especially if they are using the ordinary form of stethoscope 
with a bell-shaped chest piece, arises in case the chest piece is not 
held perfectly in apposition with the skin. If, for example, the 
stethoscope is slightly tilted to one side so that the bell is lifted 
from the skin at some point, or if one endeavors to listen over a 
very uneven part of the chest on which the bell of the stethoscope 
cannot be made to rest closely, a roar of external noises reaches the 



148 



PHYSICAL DIAGNOSIS. 



ear through the chink left between the chest piece and the chest. 
After a little practice one learns instantly to detect this condition 
of things and so to shift the position of the chest piece that exter- 
nal noises are totally excluded ; but by the beginner, the peculiar 
babel of external noises which is heard whenever the stethoscope 
fails to fit closely against the chest is not easily recognized, and 
hence he tends to attribute some of these external sounds to diseased 
conditions within the chest. 

Again, it is not until we have had considerable practice that 





Fig. 91.— Stethoscope Held Right Side Up. Fig. 92.— Stethoscope Held Wrong Side Up. 

our sense of hearing conies instantly to tell us when something is 
wrong about the stethoscope itself ; when, for example, one of the 
tubes is blocked, kinked, or disconnected, or when we are hold- 
ing the stethoscope upside down, so that the ear pieces point 
downward instead of upward (see Figs. 91 and 92). It is only 
when we have learned through long practice about how much we 
ought to hear at a given point in the normal chest that we recognize 
at once the fact that we are not hearing as much as ice should, in 
case some one of the above accidents has happened. Many begin- 
ners do not listen long enough in any one place, but move the chest 
piece of the stethoscope about rapidly from point to point, as they 
have seen experienced auscultators do ; but it is remarkable how 
much more one can hear at a given point by simply persevering and 



AUSCULTATION. 149 

listening to beat after beat, or breath after breath. It is sometimes 
difficult to avoid the impression that the sounds themselves have 
grown louder as we continue to listen, especially if we are in any 
doubt as to what we hear. Therefore, if we hear indistinctly, it is 
important to keep on listening, and to fix the attention successively 
upon each of the different elements in the sounds under consideration. 
In difficult cases we should use every possible aid toward concen- 
tration of the attention, and where it is possible, all sources of dis- 
traction should be eliminated. Thus, in any case of doubt, I think 
it is important for the auscultator to get himself into as comfort- 
able a position as he can, so that his attention is not distracted by 
his own physical discomforts. Many auscultators shut their eyes 
when listening in a difficult case so as to avoid the distraction of 
impressions coming through the sense of sight. It goes without 
saying that if quiet can be secured in the room where we are work- 
ing, and outside it as well, we shall be enabled to listen much more 
profitably. 

AUSCULTATION OF THE LUNGS. 

In the majority of cases ordinary quiet breathing is not forcible 
enough to bring out the sounds on which we depend for the diag- 
nosis of the condition of the lungs. Deep or forced breathing is 
what we need. 

As a rule, the patient must be taught how to breathe deeply, 
which is best accomplished by personally demonstrating the act of 
deep breathing and then asking him to do the same. Two difficul- 
ties are encountered : 

(a) The patient may blow out his breath forcibly and with a 
noise, since that is what he is used to doing whenever he takes a 
long breath under ordinary circumstances; or 

(b) It may be that he cannot be made to take a deep breath ?*t 
all. The first of these mistakes alters the sounds to be heard with 
the stethoscope in any part of the chest by disturbing both the 
rhythm and the pitch of the respiratory sounds In this way the 
breathing may be made to sound tubular or asthmatic throughout a 
sound chest. This difficulty can sometimes be overcome by demon- 
strating to the patient that what you desire is to have him take a 



150 



PHYSICAL DIAGNOSIS. 



full breath and then simply let it go, but not blow it forcibly out. 
In some cases the patient cannot be taught this, and we have to get 
on the best we can despite his mistakes. When he cannot be made 
to take a full breath at all, we can often accomplish the desired re- 
sult by getting him to cough. The breath just before and after a 
cough is often of the type we desire. The use of voluntary cough 
in order to bring out rales will be discussed later on. Another "use- 
ful manoeuvre is to make the patient count aloud as long as he can 
with a single breath. The deep inspiration wmich he is forced to 
take after this task is of the type which we desire. 

I. Respiratory Types. 

In the normal chest two types of breathing are to be heard : 

(1) Tracheal, bronchial, or tubular breathing. 

(2) Vesicular breathing. 

Tracheal, bronchial, or tubular breathing is to be heard in normal 
cases if the stethoscope is pressed against the trachea, and as a rule 




Fig. 93.— Situation of the Trachea and Primary Bronchi. 



it can also be heard over the situation of the primary bronchi, in 
front or behind (see Figs. 93 and 94). 

Vesicular breathing is to be heard over the remaining portions of 



AUSCULTATION. 



151 



the lung — that is, in the front of the thorax except where the heart 
and the liver come against the chest wall, in the back except where 
the presence of the scapulae obscures it, and throughout both axillae. 

(1) Characteristics of Vesicular Breathing. 

Vesicular breathing — that heard over the air vesicles or paren- 
chyma of the lung — has certain characteristics which I shall try to 
describe in terms of intensity, duration, and pitch. 




Fig. 94.— Situation of the Trachea and Primary Bronchi. 

Of the quality of the sounds heard over this portion of the lung 
there is little can be said ; it sounds something like the swish of the 
wind in a grove of trees some distance off, and hence is sometimes 
spoken of as "breezy." 

The intensity, duration, and pitch of the inspiration as compared 
with that of the expiration may be represented as in Fig. 95. In 
this figure, as in all those to be used in description of respiratory 
sounds — 

(1) I represent the inspiration by an up-stroke and the expira- 
tion by a down-stroke (see the direction of the arrows in Fig 63). 

(2) The length of the up-stroke as compared with that of the 
down-stroke corresponds to the length of inspiration compared with 
expiration. 



152 PHYSICAL DIAGNOSIS. 

(3) The thickness of the up-stroke as compared with the down' 
stroke represents the intensity of the inspiration as compared with 
the expiration. 

(4) The pitch of inspiration as compared with that of expi- 
ation is represented by the sharpness of the angle which the up- 





Fig. 95.— Vesicular Breath- Fig. 96.— Distant Vesicular Fig. 97.— Exaggerated Ve- 

ing. Breathing. slcular Breathing. 

stroke makes with the perpendicular as compared with that which 
the down-stroke makes with the perpendicular. The pitch of a 
roof may be thought of in this connection to remind ns of the mean- 
ing of these symbols. 

If now we look again at Fig. 95 we see that when compared 
with expiration (the down-stroke), the inspiration is — 

(a) More intense. 

(b) Longer. 

(c) Higher pitched. 

Our comparison is invariably made between inspiration and ex- 
piration, and not with any other sound as a standard. 

Now, this type of breathing (which, as I have said, is to be 
heard over every portion of the lung except those portions imme- 
diately adjacent to the primary bronchi), is not heard everywhere 
with equal intensity. It is best heard below the clavicles in front, 
in the axillae, and below the scapulae behind, but over the thin, 
lower edges of the lung, whether behind or at the sides, it is 
feebler, though still retaining its characteristic type as revealed in 
the inspiration and expiration in respect to intensity, duration, and 
pitch. To represent distant vesicular breathing graphically we 
nave only to draw its symbol on a smaller scale (see Fig. 96). On 



AUSCULTATION. 153 

the other hand, when one listens to the lungs of a person who has 
been exerting himself strongly, one hears the same type of respira- 
tion, but on a larger scale, which may then be represented as in 
Fig. 97. This last symbol may also be used to represent the respi- 
ration which we hear over normal but thin-walled chests ; for ex- 
ample, in children or in emaciated persons. It is sometimes known 
as "exaggerated" or "puerile" respiration. When one lung is 
thrown out of use by disease so that increased work is brought 
upon the other, the breath sounds heard over the latter are increased 
and seem to be produced on a larger scale. Such breathing is some- 
times spoken of as " rough " breathing. 

It is very important to distinguish at the outset between the 
different types of breathing, one of which I have just described, and 
the different degrees of loudness with which any one type of breath- 
ing may be heard. 

(2) Bronchial or Tracheal Breathing in Health. 

Bronchial breathing may be symbolically represented as in Fig. 
98, in which the increased length of the down stroke corresponds 
to the increased duration of expiration, and the greater thickness 



Fig. 98.— Bronchial Breath- Fig. 99.— Distant Bronchial Fig. 100.— Very Loud Bron- 

ing of Moderate Intensity. Breathing. chial Breathing. 

of both lines corresponds to the greater intensity of both sounds, 
expiratory and inspiratory, while the sharp pitch of the " gable " on 
both sides of the perpendicular corresponds to the high pitch of 
both sounds. Expiration, it will be noticed, slightly exceeds inspi- 
ration both in intensity and pitch, and considerably exceeds it in 
duration, while as compared with vesicular breathing almost all the 



154 PHYSICAL DIAGNOSIS. 

relations are reversed. Bronchial breathing has also a peculiar 
quality which can be better appreciated than described. 

In the healthy chest this type of breathing is to be heard if one 
listens over the trachea or primary bronchi (see above, Fig. 91), 
but practically one hardly ever listens over the trachea and bronchi 
except by mistake, and the importance of familiarizing one's self 
with the type of respiration heard over these portions of the chest 
is due to the fact that in certain diseases, especially in pneumonia 
and phthisis, we may hear bronchial breathing over the parenchyma, 
of the lung where normally vesicular breathing should be heard. 

The student should familiarize himself with each of these types 
of breathing, the vesicular and the bronchial, concentrating his at- 
tention as he listens first upon the inspiration and then upon the 
expiration, and comparing them with each other, first in duration, 
next in intensity, and lastly in pitch. To those who have not a 
musical ear, high-pitched sounds convey the general impression of 
being shrill, while low-pitched sounds sound hollow and empty, but 
the distinction between intensity and pitch is one comparatively 
difficult to master. Distant bronchial breathing may be repre- 
sented in Fig. 99, and is to be heard over the back of the neck 
opposite the position of the trachea and bronchi. Fig. 100 repre- 
sents very loud bronchial breathing such as is sometimes heard in 
pneumonia. 

(3) Broncho- Vesicular Breathing in Health. 

As indicated by its name, this type of breathing is intermediate 
between the two just described, hence the terms "mixed breath- 
ing," or "atypical breathing " ("unbestimmt "). Its characteristics 
may be symbolized as in Fig. 101. In the normal chest one can be- 
come familiar with broncho-vesicular breathing, by examining the 
apex of the right lung, or by listening over the trachea or one of the 
primary bronchi, and then moving the stethoscope half an inch at 
a time toward one of the nipples. In the course of this journey 
one passes over points at which the breathing has, in varying de- 
grees, the characteristics intermediate between the bronchial type 
from which we started and the vesicular type toward which we are 



AUSCULTATION. 



155 



moving. Expiration is a little longer, intenser, or higher pitched 
than in vesicular breathing, and inspiration a little shorter, feebler, 



FIG. 





A f 



-Two Common Types of Broncho- 
Vesicular Breathing. 



Fig. 102. 



-Distant Broncho-Vesicular Breath- 
ing. 



or lower pitched; but since these characteristics are variously com- 
bined, there are many subvarieties of broncho- vesicular breathing. 
Fig. 102 represents two types of distant broncho-vesicular breath- 
ing. 

(4) Emphysematous Breathing. 

A glance at Fig. 103 will call up the most important features of 
this type of respiration. The inspiration is short and somewhat 
feeble, but not otherwise remarkable. The expiration is long, 
feeble, and low pitched. This type of breathing is the rule in 
elderly persons, particularly those of the male sex. 

(5) Asthmatic Breathing. 

Fig. 104 differs from emphysematous only in the greater intensity 
of the inspiration. In this type of breathing, however, both sounds 



Fig. 103.— Emphysematous Breathing. 



Fig. 104.— Asthmatic Breathing, s, 
squeaking (musical) rales. 



are usually obscured to a great extent by the presence of piping and 
squeaking rales (see below). 



156 



PHYSICAL DIAGNOSIS. 



(6) Interrupted or " Cogwheel " Breathing. 



As a rule, only the inspiration is interrupted, being transformed 
into a series of short, jerky puffs as shown in Fig. 105. Very rarely 
the expiration is also divided into segments. When heard over the 
entire chest, cogwheel breathing is usually the result of nervous- 
ness, fatigue, or chilliness on the patient's part. With the removal 
of these causes this type of respiration then disappears. If, on the 
other hand, cogwheel respiration is confined to a relatively small 
portion of the chest, and remains present despite the exclusion of 




A< 



Fig. 105.— Cogwheel Breathing. 



Fig. 106.— Metamorphosing Breathing. 



fatigue, nervousness, or cold, it points to a local catarrh in the finer 
bronchi such as to render difficult the entrance of air into the alve- 
oli. As such, it has a certain significance in the diagnosis of early 
phthisis, a significance similar to that of rales or other signs of 
localized bronchitis (see below) . 

(7) Amphoric or Cavernous Breathing (see below, p. 161). 

(8) Metamorphosing Breathing. 

Occasionally, while we are listening to an inspiration of normal 
pitch, intensity, and quality, a sudden metamorphosis occurs and the 
type of breathmg changes from vesicular to bronchial or amphoric 
(see Fig. 106), or the intensity of the breath sounds may suddenly 
be increased without other change. These metamorphoses are usu- 
ally owing to the fact that a plugged bronchus is suddenly opened 
by the force of the inspired air, so that the sounds conducted 
through it become audible. 



? 



AUSCULTATION. 157 

II. Differences between the Two Sides of the Chest. 

Over the apex of the right lung — that is, above the right clavi- 
cle in front, and above the spine of the scapula behind — one hears 
in the great majority of normal chests a distinctly broncho-vesicu- 
lar type of breathing. In a smaller number of cases this same 
type of breathing may be heard just below the right clavicle, 
These facts cannot be too strongly insisted upon, since it is only 
by bearing them in mind that we can avoid the mistake of diagnos- 
ing a beginning consolidation of the right apex where none exists. 
Breath sounds which are perfectly normal over the right apex would 
mean serious disease if heard over similar portions of the left lung. 
It will be remembered that the apex of the right lung is also duller 
on percussion than the corresponding portion of the left, and that 
the voice sounds and tactile fremitus are normally more intense on 
the right (see Fig. 64). 

Occasionally one finds at the base of the right lung posteriorly 
a slightly feebler or more broncho-vesicular type of breathing than 
in the corresponding portion of the left lung, 

III. Pathological Modifications of Vesicular Breathing, 

Having now distinguished the different types of breathing and 
described their distribution in the normal chest, we must return to 
the normal or vesicular breathing in order to enumerate certain of 
its modifications which are important in diagnosis. 

(1) Exaggerated Vesicidar Breathing (" Compensatory" Breathing). 

(a) It has already been mentioned that in children or in adults 
with very thin and flexible chests the normal breath sounds are 
heard with relatively great distinctness ; also that after any exer- 
tion which leads to abnormally deep and forcible breathing a simi- 
lar increase in the intensity of the respiratory sounds naturally 
occurs. 

(b) The term "compensatory breathing" or "vicarious" breath- 
ing, refers to vesicular breathing of an exaggerated type, such as is 
heard, for example, over the whole of one lung when the other lung 



158 PHYSICAL DIAGNOSIS. 

is thrown out of use by the pressure of an accumulation of air or 
fluid in the pleural cavity. A similar exaggeration of the breathing 
upon the sound side takes place when the other lung is solidified, 
as by tuberculosis, pneumonia, or malignant disease, or when it is 
compressed by the adhesions following pleuritic effusion, or by 
a contraction of the bones of that side of the chest such as occurs 
in spinal curvature. 

(2) Diminished Vesicular Breathing. 

The causes of a diminution in the intensity of the breath sounds 
without any change in their type are very numerous. I shall men- 
tion them in an order corresponding as nearly as possible to the 
relative frequency of their occurrence. 

(a) Fluid, Air, or Solid in the Pleural Cavity. — Probably the 
commonest cause for a diminution or total abolition of normal 
breath sounds is an accumulation of fluid in the pleural cavity such 
as occurs in inflammation of the pleura or by transudation ( hydro - 
thorax). In such cases the layer of fluid intervening between the 
lung and the stethoscope of the auscultator causes retraction of the 
lung so that little or no vesicular murmur is produced in it, and 
hence none is transmitted to the ear of the auscultator. An ac- 
cumulation of air in the pleural cavity (pneumothorax) may dimin- 
ish or abolish the breath sounds precisely as a layer of fluid does ; 
in a somewhat different way a thickening of the costal or pulmo- 
nary pleura or a malignant growth of the chest wall may render 
the breath sounds feeble or prevent their being heard because the 
vibrations of the thoracic sounding-board are thus deadened. Which- 
ever of these causes, fluid or air or solid, intervenes between the lung 
and the ear of the auscultator, the breath sounds are deadened or 
diminished without, as a rule, any modification of their type. The 
amount of such diminution depends roughly on the thickness of the 
layer of extraneous substance, whether fluid, air, or solid. 

Total absence of breath sounds may therefore be due to any one 
of these causes, provided the layer intervening between the lung and 
chest wall is of sufficient thickness to produce complete atelectasis 
of the lung or to deaden the vibrations of the chest wall. 



AUSCULTATION. 159 

(b) Emphysema of the lung, by destroying its elasticity and re- 
ducing the extent of its movements, makes the breath sounds rela- 
tively feeble, but seldom, if ever, abolishes them altogether. 

(c) In bronchitis the breath sounds are usually considerably di- 
minished owing to the filling up of the bronchi with secretion. 
This diminution, however, usually attracts but little attention, 
owing to the fact that the bubbling and squeaking sounds, which 
result from the passage of air through the bronchial secretions, dis- 
tract our notice to such an extent that we find it difficult to con- 
centrate attention upon the breath sounds, even if we do not forget 
altogether to listen to them. When, however, we succeed in listen- 
ing through the rales to the breath sounds themselves, we usually 
notice that they are very feeble, especially over the lower two- 
thirds of the chest. (Edema of the lung may diminish the breath 
sounds in a similar way. 

(d) Pain in the thorax, such as is produced by dry pleurisy or 
intercostal neuralgia, diminishes the breath sounds because it leads 
the patient to restrain, so far as possible, the movements of his 
chest, and so of his lungs. If, for any other reason, the full ex- 
pansion of the lung does not take place, whether on account of the 
feebleness of the respiratory movements or because the lung is me- 
chanically hindered by the presence of pleuritic adhesions, the 
breath sounds are proportionately feeble. 

(e) Occlusion of the upper air passages, as by spasm or oedema 
of the glottis, renders the breathing very feeble on both sides of 
the chest. If one of the primary bronchi is occluded, as by a for- 
eign body or by pressure of a tumor or enlarged gland from without, 
we get a unilateral enfeeblement of the breathing over the corre- 
sponding lung. 

(/) Occasionally a paralysis of the muscles of respiration on one 
or both sides is found to result in a unilateral or bilateral enfeeble- 
ment of the breathing. 

It should be remembered, when estimating the intensity of the 
breathing, that the sounds heard over the right lung are, as a rule, 
slightly more feeble than those heard over the left lung in the 
normal chest. 



160 PHYSICAL DIAGNOSIS. 



IV. Bronchial or Tubular Breathing in Disease. 

(a) I have already described the occurrence of bronchial breath- 
ing in parts of the normal chest, namely, over the trachea and pri- 
mary bronchi. In disease, bronchial breathing may be heard else- 
where in the chest, and usually points to solidification of that portion 
of lung from which it is conducted. It is heard most commonly in 
phthisis (see below, p. 304). 

(b) Croupous pneumonia is probably the next most frequent 
cause of bronchial breathing, although by no means every case of 
croupous pneumonia shows this sign. For a more detailed account 
of the conditions under which it does or does not occur in croupous 
pneumonia, see below, p. 296. Lobular pneumonia is rarely mani- 
fested by tubular breathing. 

(c) In about one-third of the cases of pleuritic effusion distant 
bronchial breathing is to be heard over the fluid. On account of 
the feebleness of the breath sounds in such cases they are often 
put down as absent, as we are so accustomed to associate intensity 
with the bronchial type of breathing. One should be always on 
the watch for any degree of intensity of bronchial breathing from 
the feeblest to the most distinct. 

(d) Rarer causes of bronchial breathing are hemorrhagic infarc- 
tion of the lung, syphilis, or malignant disease, any one of which 
may cause a solidification of a portion of the lung. 

V. Broncho-Vesicular Breathing in Disease. 

Respiration of this type should be carefully distinguished from 
puerile or exaggerated breathing, in which we hear the normal vesic^ 
ular respiration upon a large scale. I have already mentioned 
that broncho- vesicular breathing is normally to be heard over the 
apex of the right lung. In disease, broncho-vesicular breathing is 
heard in other portions of the lung, and usually denotes a moderate 
degree of solidification of the lung, such as occurs in early phthisis 
or in the earliest and latest stages of croupous pneumonia. In cases 
of pleuritic effusion, one can usually hear broncho-vesicular breath- 



AUSCULTATION. 161 

ing over the upper portion of the affected side, owing to the retrac- 
tion of the lung at that point. 

VI. Amphoric Breathing [Amphora = A Jar). 

Inspirations having a hollow, empty sound like that produced 
by blowing across the top of a bottle, are occasionally heard in dis- 
ease over pulmonary cavities (e.g., in phthisis) or in pneumothorax, 
i.e., under conditions in which the air passes in and out of a large 
empty cavity within the chest. Amphoric breathing never occurs 
in health. The pitch of both sounds is low, but that of expiration 
lower than that of inspiration. The intensity and duration of the 
sounds vary, and the distinguishing mark is their quality which 
resembles that of a whispered "who." 

VII. Rales. 

The term " rales " is applied to sounds produced by the passage 
of air through bronchi which contain mucus or pus, or which are 
narrowed by swelling of their walls. 1 Hales are best classified as 
follows : 

(1) Moist or bubbling rales, including (a) coarse, (b) medium, 
and (c) fine rales. 

(2) Dry or crackling rales (large, medium, or fine) . 

The smallest varieties of this type are known as "crepitant" or 
" subcrepitant " rales. 

(3) Musical rales (high or low pitched). 

Each of these varieties will now be described more in detail. 

(1) Moist or Bubbling Rales. 

The nature of these is sufficiently indicated by their name. 
The coarsest or largest bubbles are those produced in the trachea, 
and ordinarily known as the "death rattle." Tracheal rales occur 

1 R&les are of all auscultatory phenomena the easiest to appreciate, pro- 
vided we exclude various accidental sounds which may be transmitted to the 
ear as a result of friction of the stethoscope against the skin or against the 
fingers of the observer. (See above, page 145.) 
11 



162 PHYSICAL DIAGNOSIS. 

in any condition involving either profound unconsciousness or very 
great weakness, so that the secretions which accumulate in the 
trachea are not coughed out. Tracheal rales are by no means a 
sure precursor of death, although they are very common in the 
moribund state. They can usually be heard at some distance from 
the patient and without a stethoscope. In catarrh of the larger 
bronchi large bubbling rales are occasionally to be 
V heard. In phthisical cavities one sometimes hears 
coarse, bubbling rales of a very metallic and gurgling 
quality (see below, p. 311). The finer grades of moist 
rales correspond to the finer bronchi. 

In the majority of cases moist rales are most numer- 

107 — ex- ous during inspiration and especially during the latter 

plosion of Fine part of this act. Their relation to respiration may be 

of inspiration, represented graphically as in Fig. 107, using large dots 

for coarse rales and small dots for fine rales. Musical 

rales can be symbolized by the letter S (squeaks). 

(2) Crackling Rales. 

These differ from the preceding variety merely by the absence 
of any distinct bubbling quality. They are usually to be heard in 
cases of bronchitis in which the secretions are unusually tenacious 
and viscid. They are especially apt to come at the end of inspira- 
tion, a large number being evolved in a very short space of time, so 
that one often speaks of an "explosion of fine crackling rales" at 
the end of inspiration. Crackling rales are to be heard in any one 
of the conditions in which bubbling rales occur, but are more fre- 
quent in tuberculosis than in simple bronchitis. 

Crepitant rales, which represent the finest sounds of this type, 
are very much like the noise which is heard when one takes a lock 
of hair between the thumb and first finger and rubs the hairs upon 
each other while holding them close to the ear. A very large num- 
ber of minute crackling sounds is heard following each other in 
rapid succession. To the inexperienced ear they may seem to blend 
into a continuous sound, but with practice the component parts may 



AUSCULTATION. 163 

be distinguished. This type of rales is especially apt to occur dur- 
ing inspiration alone, but not very infrequently they are heard 
during expiration as well. From subcrepitant rales they are dis- 
tinguished merely by their being still finer than the latter. ' Sub- 
crepitant rales are often mixed with sounds of a somewhat coarser 
type, while crepitant rales are usually all of a size. If the 
chest is covered with hair, sounds precisely like these two varieties 
of rales may be heard when the stethoscope is placed upon the hairy 
portions. To avoid mistaking these sounds for rales one must 
thoroughly wet or grease the hair. 

Crepitant Rales in Atelectasis. 

Crepitant and subcrepitant rales are very often to be heard along 
the thin margins of the lungs at the base of the axillae and in the 
back, especially when a patient who is breathing superficially first 
begins to take deep breaths. In such cases, they usually disappear 
after the few first respirations, and are then to be explained by the 
tearing apart of the slightly agglutinated surfaces of the finer bron- 
chioles. 

It is by no means invariably the case, however, that such sub- 
crepitant rales are merely transitory in their occurrence. In a large 
number of cases they persist despite deep breathing. The fre- 
quency of subcrepitant rales, persistent or transitory, heard over 
the inferior margin of the normal lung at the bottom of the axilla, 
is shown by the following figures : Out of 356 normal chests to 
which I have listened especially for these rales, I found 228, or 61 
per cent, which showed them on one or both sides. They are very 
rarely to be heard in persons under twenty years of age. After 
forty -five, on the other hand, it is unusual not to find them. 
In my experience they are considerably more frequent in the situa- 
tion shown in Fig. 158 than in any other part of the lung, but they 
may be occasionally hear;l in the back or elsewhere. In view of 

1 A distinction was formerly drawn between crepitant and subcrepitant 
rales, on the ground that the latter were heard during both respiratory sounds 
and the former only during inspiration, bat this distinction cannot be main- 
tained and is gradually being given up. 



164 PHYSICAL DIAGNOSIS. 

these facts, it seems to me that we must recognize that it is almost 
if not quite physiological to find the finer varieties of crackling 
rales at the base of the axillae in persons over forty years old. I 
have supposed these rales to be due to a partial atelectasis result- 
ing from disease in the thin lower margin of the lungs. Such por- 
tions of the lung are ordinarily not expanded unless the respirations 
are forced and deep. This explanation would agree with the obser- 
vations of Abrams, to which I shall refer later (see below, p. 359). 

(b) Crepitant or subcrepitant rales are also to be heard in a 
certain portion of cases of pneumonia, in the very earliest stages 
and when resolution is taking place ("crepitans redux"). More 
rarely this type of rale may be heard in connection with tubercu- 
losis, infarction, or oedema of the lung. 

In certain cases of dry pleurisy there occur fine crackling 
sounds which can scarcely be differentiated from subcrepitant rales. 
I shall return to the description of them in speaking of pleural 
friction (see below, p. 336)* 

(3) Musical Rules. 

The passage of air through bronchial tubes narrowed by inflam- 
matory swelling of their lining membrane (bronchitis), or by spas- 
modic contraction (asthma), gives rise not infrequently to a mul- 
titude of musical sounds. Such a stenosis occurring in relatively 
large bronchial tubes produces a deep-toned groaning sound, while 
narrowing of the finer tubes results in piping, squeaking, whistling 
noises of various qualities. Such sounds are often known as " dry 
rales" in contradistinction to the "bubbling rales" above described, 
but as many non-musical crackling rales have also a very dry sound, 
it seems to me best to a.pply the more distinctive term " musical 
rales " to all adventitious sounds of distinctly musical quality which 
are produced in the bronchi. Musical rales are of all adventitious 
sounds the easiest to recognize but also the most fugitive and 
changeable. They appear now here, now there, shifting from min- 
ute to minute, and may totally disappear from the chest and reap- 
pear again within a very short time. This is to some extent true* 
of all varieties of rales, but especially of the squeaking and groan- 
ing varieties. 



AUSCULTATION. 165 

Musical rales are heard, as a rule, more distinctly during expira- 
tion, especially when they occur in connection with asthma or em- 
physema. In these diseases one may hear quite complicated chords 
from the combinations of rales which vary in pitch. 

VII. The Effects of Cough. 

The influence of coughing upon rales is usually very marked. 
Its effect may be either to intensify them and bring them out where 
they have not previously been heard, or to clear them away alto- 
gether. Other effects of coughing upon physical signs will be 
mentioned later on in the chapters on Pneumonia and Phthisis. 

VIII. Pleural Friction. 

The surfaces of the healthy pleural cavity are lubricated with 
sufficient serum to make them pass noiselessly over each other dur- 
ing the movements of respiration. But when the tissues become 
abnormally dry, as in Asiatic cholera, or when the serous surfaces 
are roughened by the presence of a fibrinous exudation, as in ordi- 
nary pleurisy, the rubbing of the two pleural surfaces against one 
another produces peculiar and very characteristic sounds known as 
"pleural friction sounds." The favorite seat of pleural friction 
sounds is at the bottom of the axilla, i.e., where the lung makes 
the widest excursion and where the costal and diaphragmatic pleura 
are in close apposition (see Fig. 65). In some cases pleural fric- 
tion sounds are to be heard altogether below the level of the lung. 
In others they may extend up several inches above its lower mar- 
gin, and occasionally it happens that friction may be appreciated 
over the whole lung from the top to the bottom. Very rarely 
friction sounds are heard only at the apex of the lung in early 
tuberculosis. 

The sound of pleural friction may be closely imitated by hold- 
ing the thumb and forefinger close to the ear, and rubbing them 
past each other with strong pressure, or by pressing the palm of 
one hand over the ear and rubbing upon the back of this hand with 



166 PHYSICAL DIAGNOSIS. 

the fingers of the other. Pleural friction is usually a catchy, 
jerky, interrupted, irregular sound, and is apt to occur during in- 
spiration only, and particularly at the end of this act. It may, 
however, be heard with both respiratory acts, but rarely if ever 
occurs during expiration alone. The intensity and quality of the 
sounds vary a great deal, so that they may be compared to grazing, 
rubbing, rasping, and creaking sounds. 'They are sometimes spoken 
of as " leathery. " As a rule, they seem very near to the ear, and are 
sometimes startlingly loud. In many cases they cannot be heard 
after the patient has taken a feiv full breaths, probably because the 
rough pleural surfaces are smoothed down temporarily by the fric- 
tion which deep breathing produces. After a short rest, however, 
and a period of superficial breathing, pleural friction sounds often 
return and can be heard for a short time with all their former in- 
tensity. They are increased by pressure exerted upon the outside 
of the chest wall. Such pressure had best be made with the hand 
or with the Bowles stethoscope, since the sharp edges of the chest- 
piece of the ordinary stethoscope may give rise to considerable 
pain; but if such pressure is made with the hand, one must be 
careful not to let the hand shift its position upon the skin, else 
rubbing sounds may thus be produced which perfectly simulate 
pleural friction. In well-marked cases pleuritic friction can be 
felt if the palm of the hand is laid over the suspected area; occa- 
sionally the sound is so loud that it can be heard by the patient 
himself or by those around him. 

In doubtful cases, or when a friction sound appears to have 
disappeared, and when one wishes to bring it out again, there are 
several manoeuvres suggested by Abrams for obtaining this enr' 

(a) The Arm Manoeuvre. 

The patient suspends respiration altogether, and the arm upon 
the affected side is raised over the head by the patient himself or 
by the physician, as in performing Sylvester's method of artificial 
respiration. Duriug this movement we listen over the suspected area. 
" By this manoeuvre the movement of the parietal against the vis- 
ceral pleura is opposite in direction to that occurring during the 



AUSCULTATION. 167 

respiratory act, and for this reason the pleuritic sound may often 
be elicited after it has been exhausted in the ordinary act of breath- 

ing." 

(b) The Decubital Manoeuvre. 

" Let the patient lie upon the affected side for a minute or two, 
then let hhn rise quickly and suspend respiration. Now listen over 
the affected area, at the same time directing the patient to take a 
deep breath." 

Pleuritic friction sounds are distinguished from rales by their 
greater superficiality, by their jerky, interrupted character, by the 
fact that they are but little influenced by cough, and that they are 
increased by pressure. It has already been mentioned, however, 
that there is one variety of sounds which we have every reason to 
think originate in the pleura, which cannot be distinguished from 
certain varieties of crackling bronchial rales. Such sounds occur 
chiefly in connection with phthisical processes, in which both pleu- 
risy and bronchitis are almost invariably present, and it is seldom 
of importance to distinguish the two. 

IX. Auscultation of the Spoken or Whispered Voice Sounds. 
The more important of these is : 

(a) The Whispered Voice. 

The patient is directed to whisper "one, two, three," or 
"ninety -nine," while the auscultator listens over different portions 
of the chest to see to what degree the whispered syllables are trans- 
mitted. In the great majority of normal chests the whispered 
voice is to be heard only over the trachea and primary bronchi in 
front and behind, while over the remaining portions of the lung 
little or no sound is to be heard. When, on the other hand, solidi- 
fication of the lung is present, the whispered voice may be dis- 
tinctly heard over portions of the lung relatively distant from the 
trachea and bronchi ; for example, over the lower lobes of the lung 
behind. The usefulness of the whispered voice in the search for 
small areas of solidification or for the exact boundaries of a solidi- 



168 PHYSICAL DIAGNOSIS. 

fied area is very great, especially when we desire to save the patient 
the pain and fatigue of taking deep breaths. Whispered voice 
sounds are practically equivalent to a forced expiration and can be 
obtained with very little exertion on the patient's part. The in- 
creased transmission of the whispered voice is, hi my opinion, a 
more delicate test for solidification than tubular breathing. The 
latter sign is present only when a considerable area of lung tissue 
is solidified, while the increase of the whispered voice may be ob- 
tained over much smaller areas. Retraction of the lung above the 
level of a pleural effusion causes a moderate increase in the trans- 
mission of the whispered voice, and at times this increased or bron- 
chial whisper is to be heard over the fluid itself, probably by trans- 
mission from the compressed lung above. 

Where the lung is completely solidified the whispered words 
may be clearly distinguished over the affected area. In lesser de- 
grees of solidification the syllables are more or less blurred. 

(b) The Spoken Voice. 

The evidence given us by listening for the spoken voice in vari- 
ous parts of the chest is considerably less in value than that obtained 
through the whispered voice. As a rule, it corresponds with the 
tactile fremitus, being increased in intensity by the same causes 
which increase tactile fremitus, viz., solidification or condensation 
of the lung, and decreased by the same causes which decrease tac- 
tile fremitus — namely, by the presence of air or water in the pleu- 
ral cavity, by the thickening of the pleura itself, or by an ob- 
struction of the bronchus leading to the part over which we are 
listening. In some cases the presence of solidification of the lung 
gives rise not merely to an increase in transmission of the spoken 
voice, but to a change in its quality, so that it sounds abnormally 
concentrated, nasal, and near to the listener's ear. The latter 
change may be heard over areas where tactile fremitus is not in- 
creased, and even where it is diminished. Where this change in 
the quality of the voice occurs, the actual words spoken can often 
be distinguished in a way not usually possible over either normal 
or solidified lung. "Bronchophony," or the distinct transmission 



A USCULTATION. 169 

of audible words, aud not merely of diffuse, unrecognizable voice 
sounds, is considerably commoner in the solidifications due to pneu- 
monia than in those due to phthisis; it occurs in some cases of 
pneumothorax and pulmonary cavity. 

(c) Egophony. 

Among the least important of the classical physical signs is a 
nasal or squeaky quality of the sounds which reach the observer's 
ear when the patient speaks in a natural voice. To this peculiar 
quality of voice the name of "egophony" has been given. It is 
most frequently heard in cases of moderate-sized pleuritic effusion 
just about the level of the lower angle of the scapula and in the 
vicinity of that point. Less often it is heard at the same level in 
front. It is very rarely heard in the upper portion of the chest 
and is by no means constant either in pleuritic effusion or in any 
other condition. A point at which it is heard corresponds not, as 
a rule, with the upper level of the accumulated fluid, as has been 
frequently supposed, but often with a point about an inch farther 
down. The presence of egophony is in no way distinctive of pleu- 
ritic effusions and may be heard occasionally over solidified lung. 

X. Phenomena Peculiar to Pneumohydrothorax and Pneu- 

MOPYOTHORAX. 

(1) Succussion. 

Now and then a patient consults a physician, complaining that 
he hears noises inside him as if water were being shaken about. 
One such patient expressed himself to me to the effect that he felt 
"like a half -empty bottle." In the chest of such a patient, if one 
presses the ear against any portion of the thorax and then shakes 
the whole patient strongly, one may hear loud splashing sounds 
known technically as "succussion." Such sounds are absolutely 
diagnostic of the presence of both air and fluid in the cavity over 
which they are heard. Very frequently they may be detected by 
the physician when the patient is not aware of their presence. Oc- 



170 PHYSICAL DIAGNOSIS. 

casionally the splashing of the fluid within may be felt as well as 
heard. It is essential, of course, to distinguish succussion due to 
the presence of air and fluid in the pleural cavity from similar 
sounds produced in the stomach, but this is not at all difficult in 
the majority of cases. It is a bare possibility that succussion 
sounds may be due to the presence of air and fluid in the pericar- 
dial cavity. 

It is important to remember that succussion is never to be 
heard in simple pleuritic effusion or hydrothorax. The presence of 
air, as well as liquid, in the pleural cavity is absolutely essential to 
the production of succussion sounds. 1 

(2) Metallic Tinkle or Falling-Drop Sound. 

When listening over a pleural cavity which contains both air 
and fluid, one occasionally hears a liquid, tinkling sound, due pos- 
sibly to the impact of a drop of liquid falling from the relaxed 
lung above into the accumulated fluid at the bottom of the pleural 
cavity, and possibly to rales produced in the tissues around the 
cavity. It is stated that this physical sign may in rare cases be 
observed in large-sized phthisical cavities as well as in pneumohy- 
drothorax and pneumopyothorax. 

(3) The Lung- Fistula Sound. 

When a perforation of the lung occurs below the level of the 
fluid accumulated in the pleural cavity, bubbles of air may be forced 
out from the lung and up through the fluid with a sound reminding 
one of that made by children when blowing soap-bubbles. 

1 It is well for the student to try for himself the following experiment, 
which I have found useful in impressing these facts upon the attention of 
classes in physical diagnosis : Fill an ordinary rubber hot-water bag to the 
brim with water. Invert it and squeeze out forcibly a certain amount (per- 
haps half) of the contents, by grasping the upper end of the bag and compress- 
ing it. While the water is thus being forced out, screw in the nozzle of the 
bag. Now shake the whole bag, and it will be found impossible to produce 
any splashing sounds owing to the fact that there is no air in the bag. Un- 
screw the nozzle, admit air, and then screw it in again. Now shake the bag 
again and loud splashing will be easily heard. 



CHAPTER VIII. 

AUSCULTATION OF THE HEART. 

I. '"Valve Areas." 

In the routine examination of the heart, most observers listen 
in four places : 

(1) At the apex of the heart in the fifth intercostal space neai 
the nipple, the "mitral area." 



Aortic area. 



Tricuspid area. 




Pulmonic area. 



— j£ jt ra i area# 



Fig. 108.-The Valve Areas. 

(2) In the second left intercostal space near the sternum, the 
v pulmonic area." 

(3) In the second right intercostal space near the sternum, the 
"aortic area." 

(4) At the bottom of the sternum near the ensiform cartilage, 
the "tricuspid area." 

These points are represented in Fig. 108 and are known as 



172 PHYSICAL DIAGNOSIS. 

"valve areas" They do not correspond to the anatomical position 
of any one of the four valves, but experience has shown that sounds 
heard best at the apex can be proved (by post-mortem examination 
or otherwise) to be produced at the mitral orifice. Similarly sounds 
heard best in the second left intercostal space are proved to be 
produced at the pulmonary orifice ; those which are loudest at the 
second right intercostal space to be produced at the aortic orifice ; 1 
while those which are most distinct near the origin of the ensiform 
cartilage are produced at the tricuspid orifice. 

II. The Normal Heart Sounds. 

A glance at Fig. 109, which represents the anatomical positions 
of the four valves above referred to, illustrates what I said above ; 
namely, that the traditional valve areas do not correspond at all 
with the anatomical position of the valves. If now we listen in 
the "mitral area," that is, in the region of the apex impulse of the 
heart, keeping at the same time one finger on some point at which 
the cardiac impulse is palpable, one hears with each outward thrust 
of the heart a low, dull sound, and in the period between the heart 
beats a second sound, shorter and sharper in quality. 2 

That which occurs with the cardiac impulse is known as the 
first sound ; that which occurs between each two beats of the heart 
is known as the second sound. The second sound is generally ad- 
mitted to be due to the closure of the semilunar valves The cause 
of the first sound has been a most fruitful source of discussion, and 
no one explanation of it can be said to be generally received. Per- 
haps the most commonly accepted view attributes the first or 
systolic sound of the heart to a combination of two elements — 

(a) The contraction of the heart muscle itself. 

(b) The sudden tautening of the mitral curtains. 

Following the second sound there is a pause corresponding to 

1 For exceptions to this rule, see below, page 235. 

2 The first sound of the heart, as heard at the apex, may be imitated by- 
holding a linen handkerchief by the corners and suddenly tautening one of the 
borders. To imitate the second sound, use one-half the length of the border 
instead of the whole. 



AUSCULTATION OF THE HEART. 



173 



the diastole of the heart. Normally this pause occupies a little 
more time than the first and second sounds of the heart taken to- 
gether. In disease it may be much shortened. 

The first sound of the heart is not only longer and duller than 
the second (it is often spoken of as " booming " in contrast with the 
" snapping " quality of the second sound) but is also considerably 
more intense, so that it gives us the impression of being accented 
like the first syllable of a trochaic rhythm. After a little practice 
one grows so accustomed to this rhythm that one is apt to rely upon 



^ Aortic valve. 
_ Pulmonic valve. 



Tricuspid valve. -- — 




Mitral valve. 



/ 

Fig. 109.— Anatomical Position of the Cardiac Valves. 



his appreciation of the rhythm alone for the identification of the 
systolic sound. This is, however, an unsafe practice and leads to 
many errors. Our impression as to which of the two sounds of each 
cardiac cycle corresponds to systole should always be verified either 
by sight or touch. We must either see or feel the cardiac impulse 
and assure ourselves that it is synchronous with the heart sound 
which we take to be systolic. 1 This point is of especial importance 
in the recognition and identification of cardiac murmurs, as will be 
seen presently. 

1 When the cardiac impulse can be neither seen nor felt, the pulsation of 
the carotid will generally guide us. The radial pulse is not a safe guide. 



174 PHYSICAL DIAGNOSIS. 

So far, I have been describing the normal heart sounds heard 
in the "mitral area," that is, at the apex of the heart. If now we 
listen over the pulmonary area (in the second left intercostal 
space), we find that the rhythm of the heart sounds has changed 
and that here the stress seems to fall upon the " second sound," 
i.e., that corresponding to the beginning of diastole; in other 
words, the first sound of the heart is here heard more feebly and 
the second sound more distinctly. The sharp, snapping quality of 
the latter is here even more marked than at the apex, and despite 
the feebleness of the first sound in this area we can usually recog- 
nize its relatively dull and prolonged quality. 

Over the aortic area (i.e., in the second right interspace) the 
rhythm is the same as in the pulmonary area, although the second 
sound may be either stronger or weaker than the corresponding 
sound on the other side of the sternum (see below, p. 176). 

Over the tricuspid area one hears sounds practically indistin- 
guishable in quality and in rhythm from those heard at the apex. 

When the chest walls are thick and the cardiac sounds feeble, 
it may be difficult to hear them at all. In such cases the heart 
sounds may be heard much more distinctly if the patient leans for- 
ward and toward his own left so as to bring the heart closer to the 
front of the chest. Such a position of the body also renders it 
easier to map out the outlines of the cardiac dulness by percussion. 

In cardiac neuroses and during conditions of excitement or emo- 
tional strain, the first sound at the apex is not only very loud but 
has often a curious metallic reverberation (" cliquetis metalliqiie"') 
corresponding to the trembling, jarring cardiac impulse (often mis- 
taken for a thrill) which palpation reveals. 

III. Modifications in the Intensity of the Heart Sounds. 

It has already been mentioned that in young persons with thin, 
elastic chests, the heart sounds are heard with greater intensity 
than in older persons whose chest walls are thicker and stiffer. 
In obese, indolent adults it is sometimes difficult to hear any heart 
sounds at all, while in young persons of excitable temperament the 
sounds may have a very intense and ringing quality. Under dis- 



AUSCULTATION OF THE HEART. 175 

eased conditions either of the heart sounds may be increased or 
diminished in intensity. I shall consider 

(1) The First Sound at the Apex [sometimes Called the Mitral First 

Sound) 

(a) Increase in the length or intensity of the first sound at the 
apex of the heart occurs in any condition which causes the heart 
to act with unusual degree of force, such as bodily or mental exer- 
tion, or excitement. In the earlier stages of infectious fevers a 
similar increase in the intensity of this sound may sometimes be 
noted. Hypertrophy of the left ventricle sometimes has a similar 
effect upon the sound, but less often than one would suppose, while 
dilatation of the left ventricle, contrary to what one would suppose, 
is not infrequently associated with a loud, forcible first sound at 
the apex. In mitral stenosis the first sound is usually very intense 
and is often spoken of as a " thumping first sound " or as a " sharp 
slap." 

(b) Shortening and weakening of the first sound at the apex. 
In the course of continued fevers and especially in typhoid fever 

the granular degeneration which takes place in the heart muscle is 
manifested by a shortening and weakening of the first sound at the 
apex, so that the two heart sounds come to seem much more alike 
than usual. In the later stages of typhoid, the first sound may 
become almost inaudible. The sharp "valvular " quality, which 
one notices in the first apex sound under these conditions, has been 
attributed to the fact that weakening of the myocardium has caused 
a suppression of one of the two elements which go to make up the 
first sound, namely, the muscular element, so that we hear only the 
short, sharp sound due to the tautening of the mitral curtains. 
Chronic myocarditis, or any other change in the heart wall which 
tends to enfeeble it, produces a weakening and shortening of the 
first sound similar to that just described* Simple weakness in the 
mitral first sound without any change in its duration or pitch may 
be due to fatty overgrowth of the heart, to emphysema or pericar- 
dial effusion in case the heart is covered by the distended lung or 
by the accumulated fluid. Among valvular diseases of the heart 



176 PHYSICAL DIAGNOSIS. 

the one most likely to be associated with a diminution in intensity 
of the first apex sound is mitral regurgitation. 

(c) Doubling of the first sound at the apex. 

It is not uncommon in healthy hearts to hear in the region of 
the apex impulse a doubling of the first sound so that it may be 
suggested by pronouncing the syllables "turrupp " or "trupp." In 
health this is especially apt to occur at the end of expiration. In 
disease it is associated with many different conditions. involving an 
increase in the work of one or the other side of the heart. It 
seems, however, to be unusually frequent in myocarditis. 

(2) Modifications in the Second Sounds as Heard at the Base of the 

Heart. 

Physiological Variations. — The relative intensity of the pul- 
monic second sound, when compared with the second sound heard 
hi the conventional aortic area, varies a great deal at different pe- 
riods of life. Attention was first called to this by Vierordt, 1 and 
it has of late years been recognized by the best authorities on dis- 
eases of the heart, though the majority of current text-books still 
repeat the mistaken statement that the aortic second sound is always 
louder than the pulmonic second in health. 

The work of Dr. Sarah R. Creighton, done in my clinic during 
the summer of 1899, showed that in 90 per cent of healthy chil- 
dren under ten years of age, the pulmonic second sound is louder 
than the aortic. In the next decade (from the tenth to the twen- 
tieth year) the pulmonic second sound is louder in two-thirds of 
the cases. About half of 207 cases, between the ages of twenty and 
twenty-nine, showed an accentuation of the pulmonic second, while 
after the thirtieth year the number of cases showing such accentua- 
tion became smaller with each decade, until after the sixtieth year 
we found an accentuation of the aortic second in sixty-six out of sixty- 
eight cases examined. These facts are exhibited in tabular form in 

1 Vierordt: "Die Messung der Intensitat der Herztone" (Tubingen, 
1885). See also Hochsinger, "Die Auscultation des kindlichen Herzens"; 
Gibson, "Diseases of the Heart" (1898) ; Rosenbach, "Diseases of the Heart" 
(1900) ; Allbutt, "System of Medicine." 



AUSCULTATION OF THE HEART. 



Ill 



Figs. 110 and 111 and appear to show that the relative intensity of 
the two sounds in the aortic and pulmonic arteries depends pri- 
marily upon the age of the individual, the pulmonic sound predomi- 
nating in youth and the aortic in old age, while in the period of 
middle life there is relatively little discrepancy between the two. 



ioo%- 



90 



so%- 



33 
O 

m 

z 

H 
> 
O 
m 
co 



30%- 
20%- 



10%- 



0-9 


10-19 


20-29 


DECADES. 
30-39 J 40-49 


50-59 


60-69 


70-79 



































































































































































-—100% 

90% 

80% 

-—70% 



60% 

-—50% 
—-40% 
—30% 

20% 

•—10% 



Fig. 110.— Showing the Per Cent of Accentuated Pulmonic Second Sound in Each Decade, 

Based on 1,000 cases. 



It is, therefore, far from true to suppose that we can obtain evi- 
dence of a pathological increase in the intensity of either of the 
second sounds at the base of the heart simply by comparing it with 
the other. Pathological accentuation of the pulmonic second 
sound must mean a greater loudness of this sound than should 
be expected at the age of the patient in question, and not simply a 
greater intensity than that of the aortic second sound. The same 
12 






178 



PHYSICAL DIAGNOSIS. 



observation obviously applies to accentuation of the aortic second 
sound. 

Both the aortic and the pulmonic second sounds are sometimes 



DECADES. 



ioo9^- 


i 
0-9 


10-19 


20-29 


30-39 


40-49 


50-59 


GO- 69 


70-79 


90 %— 


















RO'K — 




































70%- 






















m 

33 

o 

m 


















> 
© 
rn 


















30 2<~ 


















20%-- 
10%— 



















































— 100% 
—-90% 

80% 

—-70% 
-—60% 
—-50% 
—40% 
—-30% 
—20% 

—-io%- 



Fig. 111.— Showing the Per Cent of Accentuated Aortic Second Sound in Each Decade. 

Based on 1,000 cases. 

very intense during great emotional excitement or after muscular 
exertion, and sometimes without any obvious cause. 

Pathological Variations. 

A. Accentuation of the Pulmonic Second Sound. 

Pathological accentuation of the second sound occurs especially 
in conditions involving a backing up of blood in the lungs, such as 
occurs in stenosis or insufficiency of the mitral valve, or in obstruc- 



AUSCULTATION OF THE HEART. 179 

tive disease of the lungs (emphysema, bronchitis, phthisis, chronic 
interstitial pneumonia). Indirectly accentuation of the pulmonic 
second sound points to hypertrophy of the right ventricle, since 
without such hypertrophy the work of driving the blood through 
the obstructed lung could not long be performed. If the right ven- 
tricle becomes weakened, the accentuation of the pulmonic second 
sound is no longer heard. 

B. Weakening of the Pulmonic Second Sound. 

"Weakening of the pulmonic second sound is a very serious symp- 
tom, sometimes to be observed in cases of pneumonia or cardiac 
disease near the fatal termination. It is thus a very important 
indication for prognosis, and is to be watched for with the greatest 
attention in such cases. 

C. Accentuation of the Aortic Second Sound. 

I have already shown that the aortic second sound is louder 
than the corresponding sound in the pulmonary area in almost every 
individual over sixty years of age and in most of those over forty. 
A still greater intensity of the aortic second sound occurs — 

(a) In interstitial nephritis or any other condition which in- 
creases arterial tension and so throws an increased amount of work 
upon the left ventricle. Indirectly, therefore, a pathologically loud 
aortic sound points directly to increased tension in the peripheral 
arteries and indirectly to hypertrophy of the left ventricle. 

(b) A similar increase in the intensity of the aortic second 
sound occurs in aneurism or diffuse dilatation of the aortic arch. 

D. Diminution in the Intensity of the Aortic Second Sound. 

Whenever the amount of blood thrown into the aorta by the 
contraction of the left ventricle is diminished, as is the case espe- 
cially in mitral stenosis and to a lesser degree in mitral regurgita- 
tion, the aortic second sound is weakened so that at the apex it 
may be inaudible. A similar effect is produced by any disease 
which weakens the walls of the left ventricle, such as fibrous myo- 



180 PHYSICAL DIAGNOSIS. 

carditis, fatty degeneration, and cloudy swelling. Relaxation of 
the peripheral arteries has the same effect. In conditions of col- 
lapse the aortic second sound may be almost or quite inaudible. 

In persons past middle life the second sounds are often louder 
hi the third or fourth interspace than in the second, so that if we 
listen only in the second space we may gain the false impression that 
the second sounds are feeble. 

Accentuation of both the second sounds at the base of the 
heart may occur in health from nervous causes or when the lungs 
are retracted by disease so as to uncover the conus arteriosus and 
the aortic arch. Under these conditions the second sound may be 
seen and felt as well as heard. In a similar way, an apparent in- 
crease in the intensity of either one of the second sounds at the 
base of the heart may be produced by a retraction of one or the 
other lung. 

Summary. — (1) The mitral first sound is increased by hyper- 
trophy or dilatation of the left ventricle, and among valvular dis- 
eases especially by mitral stenosis. It is weakened or reduplicated 
by parietal disease of the heart. Any of these changes may occur 
temporarily from physiological causes. 

(2) The pulmonic second sound is usually more intense than 
the aortic in children and up to early adult life. Later the aortic 
second sound predominates. Pathological accentuation of the sec- 
ond pulmonic sound usually points to obstruction in the pulmonary 
circulation (mitral disease, emphysema, etc.). Weakening of the 
pulmonic second means failure of the right ventricle and is serious. 

(3) The aortic second sound is increased pathologically by any 
cause which increases the work of the left ventricle (arteriosclero- 
sis, chronic nephritis). It is diminished when the blood stream, 
thrown into the aorta by the left ventricle, is abnormally small 
(mitral disease, cardiac failure). 

(4) Changes in the tricuspid sounds are rarely recognizable, 
while changes in the first aortic and pulmonic sounds have little 
practical significance. 



AUSCULTATION OF THE HEART. 181 

Modifications in the Rhythm of the Cardiac Sounds. 

(1) Whenever the walls of the heart are greatly weakened by- 
disease, for example, in the later weeks of a case of typhoid 
fever, the diastolic pause of the heart is shortened so that the car- 
diac sounds follow each other almost as regularly as the ticking of 
a clock; hence the term "tick-tack heart." As this rhythm is not 
unlike that heard hi the foetal heart, the name of " embryocardia " 
is sometimes applied to it. The " tick-tack " rhythm may be heard 
in any form of cardiac disease after compensation has failed, or in 
any condition leading to collapse. 

(2) A less common change of rhythm is that produced by a 
shortening of the interval between the two heart sounds owing to 
an incompleteness of the contraction of the ventricle. This change 
may occur in any disease of the heart when compensation fails. 

(3) The " Gallop Rhythm." — Shortening of the diastolic pause 
together with doubling of one or another of the cardiac sounds re- 
sults in our hearing at the apex of the heart three sounds instead 
of two, which follow each other in a rhythm suggesting the hoof 
beats of a galloping horse. Such a rhythm may occur temporarily in 
any heart which is excited or overworked from any cause, but when 
permanent is usually a sign of grave cardiac weakness. The rhythms 
so produced are usually anapaestic, w w — ', ^ w — ', >^w — ', or of 
this type : w — ' w, w — ' w, ^ — ' w. 

Doubling of the Second Sounds at the Base of the Heart. — At 
the end of a long inspiration this change may be observed in al- 
most any healthy person if one listens at the base of the heart. It 
is still better brought out after muscular exertion or by holding the 
breath. In such cases it probably expresses the non-synchronous 
closure of the aortic and pulmonic valves, owing to increased press- 
ure in the pulmonary circulation. Similarly in diseased condi- 
tions, anything which increases the pressure either in the periph- 
eral arteries or in the pulmonary circulation, and thus throws 
increased work upon one or the other ventricle, will cause a doub- 
ling of the second sound as heard at the base of the heart. 

In mitral stenosis a double diastolic sound is usually to be 



182 PHYSICAL DIAGNOSIS. 

heard at the apex, and in the diagnosis of this disease this " double 
shock sound" during diastole may be an important piece of evi- 
dence, and may sometimes be felt as well as heard. The " double 
shock sound " of mitral stenosis is not generally believed to repre- 
sent a doubling of the ordinary second sound, although it corre- 
sponds with diastole. Just what its mechanism is, is disputed. 

I have said nothing about modifications in the second sound at 
the apex, since this sound is now generally agreed to represent the 
aortic second sound transmitted by the left ventricle to the apex. 
The first sounds at the base of the heart have also not been dwalt 
upon, since they have no special importance in diagnosis. 

Metallic Heart Sounds. 

The presence of air in the immediate vicinity of the heart, 
as, for example, in pneumothorax or in gaseous distention of the 
stomach or intestine, may impart to the heart sounds a curious 
metallic quality such as is not heard under any other conditions. 

"Muffling," "Prolongation," or " Unelearness" of the Heart Sounds. 

These terms are not infrequently met with in literature, but 
their use should, I think, be discontinued. The facts to which 
they refer should be explained either as faintness of the heart 
sounds, due to the causes above assigned, or as faint, short mur- 
murs. In their present usage such terms as " muffled " or "unclear " 
heart sounds represent chiefly an unclearness in the mind of the 
observer as to just what it is that he hears, and not any one recog- 
nized pathological condition in the heart. 

IV. Sounds Audible Over the Peripheral Vessels. 

(1) The normal heart sounds are in adults audible over the 
carotids and over the subclavian arteries. In childhood and youth 
only the second heart sound is thus audible. 

(2) In about 7 per cent of normal persons a systolic sound can 
be heard over the femoral artery. This sound is obviously not 



AUSCULTATION OF THE HEART. 183 

transmitted from the heart, and is usually explained as a result of 
the sudden systolic tautening of the arterial wall. 

In aortic regurgitation this arterial sound is almost always 
audible not only in the femoral but in the brachial and even in the 
radial, and its intensity over the femoral becomes so great that the 
term " pistol-shot " sound has been applied to it. In fevers, 
exophthalmic goitre, lead poisoning, and other diseases, a similar 
arterial sound is to be heard much more frequently than in health. 

Venous Sounds. 

The violent closure of the venous valves in the jugular is some- 
times audible in cases of insufficiency of the tricuspid valve. The 
sound has no clinical importance, and is difficult to distinguish owing 
to the presence of the carotid first sound mentioned above* 



182 PHYSICAL DIAGNOSIS. 

heard at the apex, and in the diagnosis of this disease this " double 
shock sound" during diastole may be an important piece of evi- 
dence, and may sometimes be felt as well as heard. The " double 
shock sound " of mitral stenosis is not generally believed to repre- 
sent a doubling of the ordinary second sound, although it corre- 
sponds with diastole. Just what its mechanism is, is disputed. 

I have said nothing about modifications in the second sound at 
the apex, since this sound is now generally agreed to represent the 
aortic second sound transmitted by the left ventricle to the apex. 
The first sounds at the base of the heart have also not been dwfdt 
upon, since they have no special importance in diagnosis. 

Metallic Heart Sounds. 

The presence of air in the immediate vicinity of the heart, 
as, for example, in pneumothorax or in gaseous distention of the 
stomach or intestine, may impart to the heart sounds a curious 
metallic quality such as is not heard under any other conditions. 

"Muffling," "Prolongation" or " Unclearness " of the Heart Sounds. 

These terms are not infrequently met with in literature, but 
their use should, I think, be discontinued. The facts to which 
they refer should be explained either as faintness of the heart 
sounds, due to the causes above assigned, or as faint, short mur- 
murs. In their present usage such terms as " muffled " or " unclear " 
heart sounds represent chiefly an unclearness in the mind of the 
observer as to just what it is that he hears, and not any one recog- 
nized pathological condition in the heart. 

IV. Souxds Audible Over the Peripheral Vessels. 

(1) The normal heart sounds are in adults audible over the 
carotids and over the subclavian arteries. In childhood and youth 
only the second heart sound is thus audible. 

(2) In about 7 per cent of normal persons a systolic sound can 
be heard over the femoral artery. This sound is obviously not 



AUSCULTATION OF THE HEART. 183 

transmitted from the heart, and is usually explained as a result of 
the sudden systolic tautening of the arterial wall. 

In aortic regurgitation this arterial sound is almost always 
audible not only in the femoral but in the brachial and even in the 
radial, and its intensity over the femoral becomes so great that the 
term " pistol-shot " sound has been applied to it. In fevers, 
exophthalmic goitre, lead poisoning, and other diseases, a similar 
arterial sound is to be heard much more frequently than in health. 

Venous Sounds. 

The violent closure of the venous valves in the jugular is some- 
times audible in cases of insufficiency of the tricuspid valve. The 
sound has no clinical importance, and is difficult to distinguish owing 
to the presence of the carotid first sound mentioned above 






CHAPTER IX. 

AUSCULTATION OF THE HEAET: CONTINUED. 

Cardiac Murmurs. 

(a) Terminology. 

The word "murmur" is one of the most unfortunate of all the 
terms used in the description of physical signs. No one of the 
various blowing, whistling, rolling, rumbling, or piping ncises to 
which the term refers, sounds anything like a "murmur" in the 
ordinary sense of the word. Nevertheless, it does not seem best 
to try to replace it by any other term. The French word "souffle " 
is much more accurate and has become to some extent Anglicized. 
Under the head of cardiac murmurs are included all abnormal 
sounds produced within the heart itself. Pericardial friction 
sounds and those produced in that portion of the lung or pleura 
which overlies the heart are not considered "murmurs." 

(b) Mode of Production. 

With rare exceptions all cardiac murmurs are produced at or 
near one of the valve orifices, either by disease of the valves them- 
selves resulting in shrivelling, thickening, stiffening, and narrowing 
of the valve curtains, or by a stretching of the orifice into which 
the valves are inserted. 

Diseases of the valves themselves may lead to the production of 
murmurs : 

(a) When the valves fail to close at the proper time (incompe- 
tence, insufficiency, or regurgitation). 

(b) When the valves fail to open at the proper time (stenosis 
or obstruction) . 



AUSCULTATION OF THE HEART. 185 

(c) When the surfaces of the valves or of the parts immedi- 
ately adjacent are roughened so as to prevent the smooth flow of the 
blood over them. 

(d) When the orifice which the valves are meant to close is di- 
lated as a result of dilatation of the heart chamber of which it forms 





Fig. 112.— Diagram to Illustrate the Production of a Cardiac Murmur Through Regurgitation 
from the Aorta or in an Aneurismal Sac. The arrow shows the direction of the blood cur- 
rent and the curled lines the audible blood eddies. 

the entrance or exit. The valves themselves cannot enlarge to 
keep pace with the enlargement of the orifice, and hence no longer 
suffice to reach across it. 

The presence of any one of these lesions gives rise to eddies 
in the blood current and thereby to the abnormal sounds to which 
we give the name murmurs. 1 (See Figs. 112, 113 and 114.) When 





Fi<;. 113. -Diagram to Illustrate the Production of a Cardiac Murmur Through Stenosis of a 

Valve-Orifice. 

valves fail to close and so allow the blood to pass back through 
them, we speak of the lesion as regurgitation, insufficiency, or in- 
competence ; if, for example, the aortic valves fail to close after 
the left ventricle has thrown a column of blood into the aorta, 
some of this blood regurgitates through these valves into the ven- 

1 The method by which functional murmurs are produced will be discussed 
later. (See page 194.) 



186 PHYSICAL DIAGNOSIS. 

tricle from which it has just been expelled, and we speak of the 
lesion as "aortic regurgitation" and of the murmur so produced as 
an aortic regurgitant murmur or a murmur of aortic regurgitation. 
A similar regurgitation from the left ventricle into the left auricle 
takes place in case the mitral valve fails to close at the beginning 
of systole. If, on the other hand, the mitral valve fails to open 
properly to admit the blood which should flow during diastole from 
the left auricle into the left ventricle, we speak of the condition as 
mitral stenosis or mitral obstruction. A similar narrowing of the 
aortic valves such as to hinder the egress of blood during the systole 
of the left ventricle is known as aortic stenosis or obstruction. Val- 






Fig. 114.— Diagram to Illustrate the Production of Cardiac Murmurs Through Roughening of a 

Valve. 

vular lesions of the right side of the heart (tricuspid and pulmonic 
valves) are comparatively rare, but are produced and named in a 
way similar to those just described. 

The facts most important to know about a murmur are : 

(1) Its place in the cardiac cycle. 

(2) Its point of maximum intensity. 

(3) The area over which it can be heard. 

(4) The effects of exertion, respiration, or position upon it. 
Less important than the above are : 

(5) Its intensity. 

(6) Its quality. 

(7) Its length. 

(8) Its relation to the normal sounds of the heart. 
Each of these points will now be taken up in detail : 

(1) Time of Murmurs. — The first and most important thing to 
ascertain regarding a murmur is its relation to the normal cardiac 
cycle ; that is, whether it occurs during systole or during diastole, 
or in case it does not fill the whole of one of those periods, in what 



AUSCULTATION OF THE HEART. 187 

part of systole or diastole it occurs. It must be borne in mind that 
the period of systole is considered as lasting from the beginning of 
the first sound of the heart up to the occurrence of the second 
sound, while diastole lasts from the beginning of the second sound 
until the beginning of the first sound in the next cycle. Any mur- 
mur occurring with the first sound of the heart, or at the time when 
the first sound should take place, or in any part of the period inter- 
vening between the first sound and the second, is held to be systolic. 
Murmurs which distinctly follow the first sound or do not begin 
until the first sound is ended are known as late systolic murmurs. 

On the other hand, it seems best, for reasons to be discussed 
more in detail later on, not to give the name of diastolic to all 
murmurs which occur within the diastolic period as above defined. 
Murmurs which occur during the last part of diastole and which 
run up to the first sound of the next cycle are usually known as 
"presystolic " murmurs. All other murmurs occurring during dias- 
tole are known as diastolic. 

The commonest of all the errors in the diagnosis of disease of 
the heart is to mistake systole for diastole, and thereby to misin- 
terpret the significance of a murmur heard during those periods. 
This mistake would never happen if we were always careful to 
make sure, by means of sight or touch, just when the systole of 
the heart occurs. This may be done by keeping one finger upon 
the apex impulse of the heart or upon the carotid artery while 
listening for murmurs, or, in case the apex impulse or the pulsa- 
tions of the carotid are better seen than felt, we can control by the 
eye the impressions gained by listening. It is never safe to trust 
our appreciation of the cardiac rhythm to tell us which is the first 
heart sound and which the second. The proof of this statement 
is given by the numberless mistakes made through disregarding it. 
Equally untrustworthy as a guide to the time of systole and dias- 
tole is the radial pulse, which follows the cardiac systole at an 
interval just long enough to mar our calculations. 

(2) Localizations of Murmurs. — To localize a murmur is to find 
its point of maximum intensity, and this is of the greatest impor- 
tance in diagnosis. Long experience has shown that murmurs 



188 PHYSICAL DIAGNOSIS. 

heard loudest in the region of the apex beat (whether this is in the 
normal situation or displaced), are in the vast majority of cases pro- 
duced at the mitral valve. In about five per cent of the cases mitral 
murmurs may be best heard at a point midway between the position 
of the normal cardiac impulse and the ensiform cartilage, or (very 
rarely) an inch or two above this situation. 

Murmurs heard most loudly in the second left intercostal space 
are almost invariably produced at the pulmonic orifice or just above 
it in the conus arteriosus. 

Murmurs whose maximum intensity is at the root of the ensi- 
form cartilage or within a radius of an inch and a half from this 
point are usually produced at the tricuspid orifice. Murmurs pro- 
duced at the aortic orifice may be heard best in the aortic area, but 
in a large proportion of cases are loudest on the other side of the 
sternum at or about the situation of the fourth left costal cartilage. 
Occasionally they are best heard at the apex of the heart or over 
the lower part of the sternum (see below, Fig. 137). 

(3) Transmission of Murmurs. — If a murmur is audible over sev- 
eral valve areas, the questions naturally arise: "How are we to 
know whether we are dealing with a single valve lesion or with 
several? Is this one murmur or two or three murmurs? " Obvi- 
ously the question can be asked only in case the murmur which we 
find audible in various places occupies everywhere the same time 
in the cardiac cycle. It must, for example, be everywhere systolic 
or everywhere diastolic. A systolic murmur at the apex cannot 
be supposed to point to the same lesion as a diastolic murmur, no 
matter where the latter is heard. But if we hear a systolic mur- 
mur in various parts of the chest, say over the aortic, mitral, and 
tricuspid regions, how are we to know whether the sound is simple 
or compound, whether produced at one valve orifice or at several? 

This question is sometimes difficult to answer, and in a given 
case skilled observers may differ in their verdict, but, as a rule, the 
difficulty may be overcome as follows : 

(1) Experience and post-mortem examination have shown that 
the murmur produced by each of the valvular lesions has its own 
characteristic area of propagation, over which it is heard with an in- 



AUSCULTATION OF THE HEART. 



189 



tensity which regularly diminishes as we recede from a maximum 
whose seat corresponds with some one of the valve areas just de- 
cribed. These areas of propagation are shown in Figs. 125, 126, 129, 
and 134. Any murmur whose distribution does not extend beyond 
one of these areas, and which steadily and progressively diminishes 
in intensity as we move away from the valve area over which it is 
loudest ? may be assumed to be due to a single valve lesion and no 




Fig. 115.— Mitral and Tricuspid Regurgitation. The intensity of the systolic murmur is least at 
the " waist " of the shaded area and increases as one approaches either end of it. 



more. Provided but one valve is diseased, this course of procedure 
gives satisfactory results. 

(2) When several valves are diseased and several murmurs may 
be expected, it is best to start at some one valve area, say in the 
mitral or apex region, and move the stethoscope one-half an inch 
at a time toward one of the other valve areas, noting the intensity 
of any murmur we may hear at each of the different points passed 
over. As we move toward the tricuspid area, we may get an im- 
pression best expressed by Fig. 115. That is, a systolic murmur 
heard loudly at the apex may fade away as we move toward the 
ensiform, until at the point x (Fig. 115) it is almost inaudible. But 
as we go on in the same direction the murmur may begin to grow 



190 PHYSICAL DIAGNOSIS. 

louder (and perhaps to change in pitch and quality as well) until a 
maximum is reached at the tricuspid area, beyond which the mur- 
mur again fades out. 

These facts justify us in suspecting that we are dealing with two 
murmurs, one produced at the tricuspid and one at the mitral ori- 
fice. The suspicion is more likely to be correct if there has been 
a change in the pitch and quality of the murmur as we n eared the 
tricuspid orifice, and may be confirmed by the discovery of other 
evidences of a double lesion. No diagnosis is satisfactory which 
rests on the evidence of murmurs alone. Changes in the size of 
the heart's chambers or in the pulmonary or peripheral circulations 
are the most important facts in the case. Nevertheless the effort 
to ascertain and graphically to represent the intensity of cardiac 
murmurs as one listens along the line connecting the valve areas 
has its value. An "hour-glass " murmur, such as that represented 
in Fig. 115), generally means two-valve lesions. A similar "hour- 
glass " may be found to represent the auditory facts as we move 
from the mitral to the pulmonic or to the aortic areas (see Fig. 
116) and, as in the previous case, arouses our suspicion that more 
than one valve is diseased. 

It must not be forgotten, however, that " a murmur may travel 
some distance underground and emerge with a change of quality " 
( Allbutt) . This is especially true of aortic murmurs, which are often 
heard well at the apex and at the aortic area, and faintly in the in- 
tervening space, probably owing to the interposition of the right 
ventricle. 

In such cases we must fall back upon the condition of the heart 
itself, as shown by inspection, palpation, and percussion, and upon 
the condition of the pulmonary and peripheral circulation, as 
shown in the other symptoms and signs of the cases (dropsy, cough, 
etc.). 

(4) Intensity of Murmurs. — Sometimes murmurs are so loud 
that they are audible to the patient himself or even at some dis- 
tance from the chest. In one case I was able to hear a murmur 
eight feet from the patient. Such cases are rare and usually not 
serious, for the gravity of the lesion is not at all proportional to 



AUSCULTATION OF THE HEART. 



191 



the loudness of the murmur; indeed, other things being equal, 
loud murmurs are less serious than faint ones, provided we are sure 
we are dealing with organic lesions. (On the distinction between 
the orgauic and functional murmurs, see below, p. 196.) 

A loud murmur means a powerful heart driving the blood 
strongly over the diseased valve. When the heart begins to fail, 
the intensity of the murmur proportionately decreases because the 
blood does not flow swiftly enough over the diseased valve to pro- 




ne. 116. 



Mitral Regurgitation and Aortic Stenosis. The systolic murmur is loudest at the ex- 
tremities of the shaded area and faintest at its 



duce as loud a sound as formerly. The gradual disappearance of 
a murmur known to be due to a valvular lesion is, therefore, a very 
grave sign, and its reappearance revives hope. Patients are not 
infrequently admitted to a hospital with valvular heart trouble 
which has gone on so long that the muscle of the heart is no longer 
strong enough to produce a murmur as it pumps the blood over the 
diseased valve. In such a case, under the influence of rest and 
cardiac tonics, one may observe the development of a murmur as 
the heart wall regains its power, and the louder the murmur be- 
comes the better the condition of the patient. On the other hand, 
when the existence of a valvular lesion has been definitely deter- 



192 PHYSICAL DIAGNOSIS. 

mined, and yet the compensation remains perfectly good (for exam- 
pie, in the endocarditis occurring in children in connection with 
chorea) , an increase in the loudness of the murmur may run paral- 
lel with the advance in the valvular lesion. 

In general the most important point about the intensity of a 
murmur is its increase or decrease while under observation, and not 
its loudness at any one time. 

(5) Quality of Heart Murmurs. — It has been already mentioned 
that the quality of a heart murmur is never anything like the 
sound which we ordinarily designate by the word "murmur." The 
commonest type of heart murmur has a blowing quality, whence the 
old name of " bellows sound. " The sound of the letter " f " pro- 
longed is not unlike the quality of certain murmurs. Blowing 
murmurs may be low-pitched like the sound of air passing through 
a large tube, or high-pitched approaching the sound of a whistle. 
This last type merges into that known as the musical murmur, in 
which there is a definite musical sound whose pitch can be identi- 
fied. Rasping or tearing sounds often characterize the louder 
varieties of murmurs. 

Finally, there is one type of sound which, though included 
under the general name murmur, differs entirely from any of the 
other sounds just described. This is the u presystolic roll," which 
has a rumbling or blubbering quality or may remind one of a short 
drum-roll. This murmur is always presystolic in time and usually 
associated with obstruction at the mitral or tricuspid valves. Not 
infrequently some part of a cardiac murmur will have a musical 
quality while the rest is simply blowing or rasping in character. 
Musical murmurs do not give us evidence either of an especially 
serious or especially mild type of disease. Their chief importance 
consists in the fact that they rarely exist without some valve 
lesion, 1 and are, therefore, of use in excluding the type of mur- 
mur known as "functional" presently to be discussed, and not 
due to valve disease. Very often rasping murmurs are associated 
either with the calcareous deposit upon a valve or very marked 
narrowing of the valve orifice. 

1 Rosenbach holds that they may he produced by adhesive pericarditis. 



AUSCULTATION OF THE HEART, 193 

Murmurs may be accented at the beginning or the end ; that is. 
the j may be of the crescendo type, growing louder toward the end, 
or of the decrescendo type with their maximum intensity at the 
beginning. Almost all murmurs are of the latter type except those 
associated with mitial or tricuspid obstruction. 

(6) Length of Murmurs. — Murmurs may occupy the whole 
of systole, the whole of diastole, or only a portion of one of 
these periods, but no conclusions can be drawn as to the severity 
of the valve lesion from the length of the murmur. A short mur- 
mur, especially if diastolic, may be of very serious prognostic im- 
port. 

(7) Relations to the Normal Sounds of the Heart. — Cardiac mur- 
murs may or may not replace the normal heart sounds. They may 
occur simultaneously with one or both sounds or between the 
sounds. These facts have a certain amount of significance in prog- 
nosis. Murmurs which entirely replace cardiac sounds usually mean 
a severer disease of the affected valve than murmurs which accom- 
pany, but do not replace, the normal heart sounds. Late systolic 
murmurs, which occur between the first and the second sound, are 
usually associated with a relatively slight degree of valvular dis- 
ease. Late diastolic murmurs, on the other hand, have no such 
favorable significance. 

(8) Effects of Position, Exercise, and Respiration upon Cardiac 
Murmurs. — Almost all cardiac murmurs are affected to a greater 
or less extent by the position which the patient assumes while he 
is examined. Systolic murmurs which are inaudible while the 
patient is in a sitting or standing position may be quite easily 
heard when the patient lies down. On the other hand, a pre- 
systolic roll which is easily heard when the patient is sitting up 
may entirely disappear when he lies down. Diastolic murmurs 
are relatively little affected by the position of the patient, but 
in the majority of cases are somewhat louder in the upright posi- 
tion. 

The effects of exercise may perhaps be fitly mentioned here. 
Feeble murmurs may altogether disappear when the patient is at 
rest, and under such circumstances may be made easily audible by 
13 



194 PHYSICAL DIAGNOSIS. 

getting the patient to walk briskly np and down the room a few 
times. Such lesions are usually comparatively slight. 1 On the 
other hand, murmurs which become more marked as a result of rest 
are generally of the severest type (see above, p. 190). 

Organic murmurs are usually better heard at the end of expira- 
tion and become fainter during inspiration as the expanding lung 
covers the heart. This is especially true of those produced at the 
mitral valve, and is in marked contrast with the variations Of func- 
tional murmurs which are heard chiefly or exclusively at the end of 
inspiration. 

(9) Sudden Metamorphosis of Murmurs. — In acute endocarditis, 
when vegetations are rapidly forming and changing their shape 
upon the valves, murmurs may appear and disappear very sud- 
denly. This metamorphosing character of cardiac murmurs, when 
taken in connection with other physical signs, may be a very im- 
portant factor in the diagnosis of acute endocarditis. In a similar 
way relaxation or rupture of one of the tendinous cords, occurring 
in the course of acute endocarditis, may effect a very sudden change 
in the auscultatory phenomena. 

"Functional Murmurs." 

Not every murmur which is to be heard over the heart points to 
disease either in the valves or in the orifices of the heart. Perhaps 
the majority of all murmurs are thus unassociated with valvular 
disease, and to such the name of "accidental," "functional," or 
" hsemic " murmurs has been given. The origin of these " functional " 
murmurs has given rise to an immense amount of controversy, and 
it cannot be said that any one explanation is now generally agreed 
upon. To me the most plausible view is that which regards most 
of them as due either to a temporary or permanent dilatation of 
the conus arteriosus, or to pressure or suction exerted upon the 
overlapping lung margins by the cardiac contractions. This ex- 
plains only the systolic functional murmurs, which make up ninety- 
nine per cent, of all functional murmurs. The diastolic functional 
murmurs, which undoubtedly occur, although with exceeding rarity, 
1 For exception to this see below, page 215. 



AUSCULTATION OF THE HEART. 195 

are probably due in most cases to sounds produced in the veins of 
the neck and transmitted to the innominate or vena cava. 

Characteristics of Functional Murmurs. — (1) Almost all func- 
tional murmurs are systolic, as has before been mentioned. 

(2) The vast majority of them are heard best over the pulmonic 
valve in the second left intercostal space. From this point they 
are transmitted in all directions, and are frequently to be heard, al- 
though with less intensity, in the aortic and mitral areas. Occa- 
sionally they may have their maximum intensity in one of the latter 
positions. 

(3) As a rule, they are very soft and blowing in quality, though 
exceptionally they may be loud and rough. 

(4) They are not associated with any evidence of enlargement 
of the heart nor with accentuation of the pulmonic second sound. ' 

(5) They are usually louder at the end of inspiration. 

(6) They are usually heard over a very limited area and not 
transmitted to the left axilla or to the back. 

(7) They are especially evanescent in character ; for example, 
they may appear at the end of a hard run or boat race or during 
an attack of fever, and disappear within a few days or hours. Res- 
piration, position, and exercise produce greater variations in them 
than in "organic" murmurs. 

(8) They are especially apt to be associated with anaemia, 
although the connection between ansemia and functional heart mur- 
murs is by no means as close as has often been supposed. The 
severest types of ansemia, for example pernicious ansemia, may not 
be accompanied by any murmur, while, on the other hand, typical 
functional murmurs are often heard in patients whose blood is nor- 
mal, and. even in full health. Yet in three cases of intense anaemia 
I have heard diastolic murmurs loudest at the fourth left costal car- 
tilage and leading to a diagnosis of aortic regurgitation. At au- 
topsy the aortic valves were in each case sound, and I am at a loss 

1 In chlorosis the second pulmonic sound is often very loud (owing to the 
retraction of the lungs and uncovering of the conus arteriosus) and associated 
with a systolic murmur. 



196 PHYSICAL DIAGNOSIS. 

to account for the murmurs. ' It should not be forgotten that a 
real, though temporary, leakage through the mitral or tricuspid 
valve may be associated with anaemia or debilitated conditions 
owing to weakening of the papillary muscles or of the mitral 
sphincter. In such cases we find not the signs of a functional 
murmur, as above described, but the evidence of an organic valve 
lesion hereafter to be described. 

The distinctions between organic and functional heart murmurs 
may be summed up as follows : 

Organic murmurs may occupy any part of the cardiac cycle ; if 
systolic, they are usually transmitted either into the axilla and 
back or into the great vessels of the neck ; they are usually asso- 
ciated with evidences of cardiac enlargement and changes in the sec- 
ond sounds at the base of the heart, as well as with signs and symp- 
toms of stasis in other organs. Organic murmurs not infrequently 
have a musical or rasping quality, although this is by no means al- 
ways the case. They are rarely loudest in the pulmonic area and 
are relatively uninfluenced by respiration, position, or exercise. 

Functional murmurs are almost always systolic in time and 
usually heard with maximum intensity in the pulmonic area. They 
are rarely transmitted beyond the precordial region and are usually 
loudest at the end of inspiration. They are not accompanied by 
evidences of cardiac enlargement or pathological accentuation of 
the second sounds at the base of the heart, nor by signs of venous 
stasis or dropsy. They are very apt to be associated with anaemia 
or with some special attack upon the resources of the body {e.g., 
physical overstrain or fever), and to disappear when such forces are 
removed. They are usually soft in quality; never musical. The 
very rare diastolic functional murmur occurs exclusively, so far as 
I am aware, in conditions of profound anaemia; i.e., when the haemo- 
globin is twenty -five per cent or less. It can be abolished by press- 
ure upon the bulbus jugularis, and can be observed, if followed up 
into the neck, to pass over gradually into a continuous venous hum 
with a diastolic accent. 

1 Cabot and Locke, Johns Hopkins Bulletin, May, 1903. 



AUSCULTATION OF THE HEART 197 

Ca rdio-Respira tory Murmurs. 

When a portion of the free margin of the lung is fixed by ad- 
hesions in a position overlapping the heart, the cardiac movements 
may rhythmically displace the air in such piece of lung so as to 
give rise to sounds which at times closely simulate cardiac mur- 
murs. These conditions are most often to be found in the tongue- 
like projection of the left lung, which normally overlaps the heart, 
but it is probably the case that cardio-respiratory murmurs may be 
produced without any adhesion of the lung to the pericardium 
under conditions not at present understood. Such murmurs may 
be heard under the left clavicle or below the angle of the left scap- 
ula, as well as near the apex of the heart, — less often in other parts 
of the chest. 

Cardio-respiratory murmurs may be either systolic or diastolic, 
but the vast majority of cases are systolic. The area over which 
they are audible is usually a very limited one. They are greatly 
affected by position and by respiration, and are heard most distinctly 
if not exclusively during inspiration, especially at the end of that 
act. (This fact is an important aid in distinguishing them from 
true cardiac murmurs, which are almost always fainter at the end 
of inspiration.) They are also greatly affected by cough or forced 
respiration or by holding the breath, whereas cardiac murmurs 
are relatively little changed thereby. Pressure on the outside 
of the thorax and in their vicinity may greatly modify their in- 
tensity or quality, while organic cardiac murmurs are but little 
influenced by pressure. As a rule, they have the quality of nor- 
mal respiratory murmur, and sound like an inspiration interrupted 
by each diastole of the heart. 

In case the effect of the cardiac movements is exerted upon a 
piece of lung in which a catarrhal process is going on, we may have 
systolic or diastolic explosions of rales, or any type of respiratory 
murmur except the bronchial type, since this is produced in solid lung 
which could not be emptied or filled under the influence of the car- 
diac movements. Cardio-respiratory murmurs have no special diag- 
nostic significance, and are mentioned here only on account of the im- 



198 PHYSICAL DIAGNOSIS. 

portance of not confusing them with true cardiac murmurs. They 
were formerly thought to indicate phthisis, but such is not the case. 

Murmurs of Venous Origin. 

I have already mentioned that the venous hum so often heard 
in the neck in cases of anaemia may be transmitted to the region of 
the base of the heart and heard there as a diastolic murmur owing 
to the acceleration of the venous current by the aspiration of the 
right ventricle during diastole. Such murmurs are very rare and 
may usually be obliterated by pressure upon the bulbus jugularis, 
or even by the compression brought to bear upon the veins of the 
neck when the head is sharply turned to one side. They are heard 
better in the upright position and during inspiration. 

Arterial Murmurs. 

(1) Eoughening of the arch of the aorta, due to chronic endo- 
carditis, is a frequent cause in elderly men of a systolic murmur, 
heard best at the base of the heart and transmitted into the vessels 
of the neck. Such a murmur is sometimes accompanied by a pal- 
pable thrill. From cardiac murmurs it is distinguished by the lack 
of any other evidence of cardiac disease and the presence of marked 
arterio-sclerosis in the peripheral vessels (see further discussion 
under Aortic Stenosis, p. 239, and under Aneurism, p. 282. 

(2) A narrowing of the lumen of the subclavian artery, due to 
some abnormality in its course, may give rise to a systolic mur- 
mur heard close below the clavicle at its outer end. The mur- 
mur is greatly influenced by movements of the arm and especially 
by respiratory movements. During inspiration it is much louder, 
and at the end of a forced expiration it may disappear altogether. 
Occasionally such murmurs are transmitted through the clavicle so 
as to be audible above it. 

(3) Pressure exerted upon any of the superficial arteries (carot- 
id, femoral, etc.) produces a systolic murmur (see below, p. 237). 
Diastolic arterial murmurs are peculiar to aortic regurgitation. 

(4) Over the anterior fontanelle in infants and over the gravid 
uterus systolic murmurs are to be heard which are probably arterial 
in origin. 



CHAPTER X. 
DISEASES OF THE HEART. 

VALVULAR LESIONS. 

Clinically it is convenient to divide the ills which befall the 
heart into three classes : 

(1) Those which deform the cardiac valves (valvular lesions). 

(2) Those which weaken the heart wall (parietal disease). 

(3) Congenital malformations. 

Lesions which affect the cardiac valves without deforming them 
are not often recognizable during life. The vegetations of acute 
endocarditis 1 do not usually produce any peculiar physical signs 
until they have so far deformed or obstructed the valves as to pre- 
vent their opening or closing properly. 

The murmurs which are often heard over the heart in cases of 
acute articular rheumatism cannot be considered as evidence of 
vegetative endocarditis unless valvular deformities, and their re- 
sults in valvular obstruction or incompetency, ensue. The chordae 
tendinese may be ruptured or shortened, thickened, and welded to- 
gether into shapeless masses, but if these deformities do not affect 
the action of the valves we have no means of recognizing them dur- 
ing life. Congenital malformations are practically unrecognizable 
as such. If they do not affect the valves, we cannot with any cer- 
tainty make out what is wrong. 

For physical diagnosis, then, heart disease means either de- 
1 See Appendix. 



200 



PHYSICAL DIAGNOSIS. 



formed valves of weakened walls. Whatever else may exist, we 
are none the wiser for it unless the autopsy enlightens us. 

In this chapter I shall confine myself to the discussion of valvu- 
lar lesions and their results. 

Valvular lesions are of two types : 

(a) Those which produce partial obstruction of a valve orifice 
or prevent its opening fully ("stenosis "). 




Fig. 117.— The Base of the Contracted Heart Showing- Pptiincteric Action of the Muscular Fibres 
Surrounding the Mitral and Tricuspid Valves. The outer dotted line is the outline of the 
relaxed heart. The inner dotted circles show the size of the mitral and tricuspid valves 
during diastole, a, Outline of the heart when relaxed ; b, outline of the relaxed tricuspid 
valve ; c, outline of the mitral orifice during diastole. (Af er Spalteholz.) 



(b) Those which produce leakage through a valve orifice or 
prevent its closing effectively ("regurgitation" "insufficiency " 
* k incompetency "). 



VALVULAR LESIONS. 



201 



Stenosis results always from the stiffening, thickening, and con- 
traction of a valve. 

Regurgitation, on the other hand, may be the result either of — 

(«) Deformity of a valve, or 

(b) Weakening of the heart muscle. 

The mitral and tricuspid orifices are closed not simply by the 
shutting of their valves, but also in part by the sphincter-like 

Mitral curtains. 



Chordea 
tendiueae. 



Papillary 
muscle. 




Myocardium. 



Pericardium. 



Fig. 118.— The Mitral Valve Closed, Showing tbe Action of the Papillary Muscles. (After 

Spalteholz.) 



action of the circular fibres of the heart wall (see Fig. 117) and the 
contraction of the papillary muscles (Fig. 118). 

In birds the tricuspid orifice has no valve and is closed wholly 
by the muscular sphincter of the heart wall. 

In conditions of the acute cardiac failure, such as may occur 
after a hard run, the papillary muscles are in all probability relaxed, 
so that the valve-flaps swing back into the auricle and permit regur- 
gitation of blood from the vertricle. 



202 PHYSICAL DIAGNOSIS. 

Valvular incompetence, then, differs from valvular obstruction 
in that the latter always involves deformity and stiffening of valves, 
while incompetence or leakage is often the result of deficient mus- 
cular action on the part of the heart wall. An osbtructed valve is 
almost always leaky as well, since the same deformities which pre- 
vent a valve from opening usually prevent its closure ; but this rule 
does not ivork backward. A leaky valve is often not obstructed. 
It is leaky but not osbtructed if the valve curtain has been practi- 
cally destroyed by endocarditis ; or, again, it is leaky but not ob- 
structed if the leak represents muscular weakening of the mitral 
sphincter or of the papillary muscles. Pure stenosis is very rare. 
Pure regurgitation is very common. 

When valves are so deformed that their oriiice is both leaky and 
obstructed, we have what is known as a " combined " or " double " 
valve lesion. 

Since valvular lesions are recognized largely by their results, 
first upon the walls of the heart itself and then upon the other 
organs of the body, it seems best to give some account of these 
results before passing on to the description of the individual le- 
sions in the heart itself. 

The results of valvular lesions are first conservative and later 
destructive. The conservative results are known sis : 

The establishment of compensation through hypertrophy. 

The destructive or degenerative results are known as : 

The failure of compensation through (or without) dilatation. 

I shall consider, then, 

(a) The establishment and the failure of compensation. 

(b) Cardiac hypertrophy. 

(c) Cardiac dilatation. 



ESTABLISHMENT AND FAILURE OF COMPENSATION IN 
VALVULAR DISEASE OF THE HEART. 

We may discriminate three periods in the progress of a case ol 
valvular heart disease : 



VALVULAR LESIONS. 203 

(1) The period before the establishment of compensation. 

(2) The period of compensation. 

(3) The period of failing or ruptured compensation. 

(1) Compensation Not Yet Established. 

In most cases of acute valvular endocarditis, whether of the 
relatively benign or of the malignant type, there is a time when 
the lesion is perfectly recognizable despite the fact that compensa- 
tory hypertrophy has not yet occurred. In some cases this period 
may last for months ; the heart is not enlarged, there is no accentu- 
ation of either second sound at the base, there is no venous stasis, 
and our diagnosis must rest solely upon the presence and character- 
istics of the murmur. For example, in early cases of mitral regur- 
gitation due to chorea or rheumatism, the disease may be recog- 
nized by the presence of a loud musical murmur heard in the back 
as well as at the apex and in the axilla. In the earlier stages of 
aortic regurgitation occurring in young people as a complication of 
rheumatic fever, there may be absolutely no evidence of the valve 
lesion except the characteristic diastolic murmur. In most text- 
books of physical diagnosis I think too little attention is given to 
this stage of the disease. 

(2) The Period of Compensation. 

Valvular disease would, however, soon prove fatal were it not 
for the occurrence of compensatory hypertrophy of the heart walls. 
To a certain extent the heart contracts as a single muscle, and in- 
creases the size of all its walls in response to the demand for in- 
creased work ; but as a rule the hypertrophy affects especially one 
ventricle — that ventricle, namely, upon which especially demand is 
made for increased power in order to overcome an increased resist- 
ance in the vascular circuit which it supplies with blood. What- 
ever increases the resistance in the lungs brings increased work 
upon the right ventricle ; whatever increases the resistance in the 
aorta or peripheral arteries increases the amount of work which the 
left ventricle must do, 



204 PHYSICAL DIAGNOSIS. 

Now, any disease of the mitral valve, whether obstruction or 
leakage, results in engorgement of the lungs with blood, and hence 
demands an increased amount of work on the part of the right 
ventricle in order to force the blood through the overcrowded pul- 
monary vessels ; hence it is in mitral disease that we find the great- 
est compensatory hypertrophy of the right ventricle. 

On the other hand, it is obvious that obstruction at the aortic 
valves or in the peripheral arteries (arterio-sclerosis) demands an 
increase in power in the left ventricle, in order that the requisite 
amount of blood may be forced through arteries of reduced calibre, 
while if the aortic valve is so diseased that a part of the blood 
thrown into the aorta by the left ventricle returns into that ven- 
tricle, its work is thereby greatly increased, since it has to contract 
upon a larger volume of blood. 

In response to these demands for increased work, the muscular 
wall of the left ventricle increases in thickness, and compensation is 
thus established at the cost of an increased amount of work on the 
part of the heart. 1 

(3) Failure of Compensation. 

Sooner or later in the vast majority of cases the heart, handi- 
capped as it is by a leakage or obstruction of one or more valves, 
becomes unable to meet the demands made upon it by the needs of 
the circulation. Failure of compensation is sometimes associated 
with dilatation of the heart and weakening of its walls, but in 
many cases no such change can be found to account for its failure, 
and we have to fail back upon changes in the nutrition of the 
heart wall or upon some hypothetical derangement of the ner- 
vous mechanism of the organ as an explanation. Whatever the 
cause may be, the result of ruptured compensation is venous stasis ; 
that is, oedema or dropsy of various organs appears. If the 
left ventricle is especially weakened, dropsy appears first in the 
legs, on account of the influence of gravity, soon after in the geni- 

1 Rosenbach brings forward evidence to show that the arteries, the lungs, 
and other organs actively assist in maintaining compensation. 



VALVULAR LESIONS. 205 

tals, lungs, liver, and the serous cavities. Engorgement of the 
lungs is especially marked in cases of mitral disease with weakening 
of the right ventricle, and is manifested by dyspnoea, cyanosis, 
cough, and haemoptysis. In many cases, however, dropsy is very 
irregularly and unaccountably distributed, and does not follow the 
rules just given. In pure aortic disease, uncomplicated by leakage 
of the mitral valve, dropsy is a relatively late symptom, and dysp- 
noea and precordial pain (angina pectoris) are more prominent. 

HYPERTROPHY AND DILATATION. 

Since cardiac hypertrophy or dilatation are not in themselves 
diseases, but may occur in any disease of the heart (valvular or 
parietal), it seems best to give some account of them and of the 
methods by which they may be recognized, before taking up sepa- 
rately the different lesions with which they are associated. 



1. Cardiac Hypertrophy. 

Hypertrophy of the heart is usually due to the following causes : 

First (and most frequent) : Valvular disease of the heart itself. 
Second: Obstruction of the flow of blood through the arteries 
owing to increase of arterial resistance, such as occurs in chronic 
nephritis and arterio-sclerosis. Third : Obstruction to the circula- 
tion of the blood through the lungs (emphysema, cirrhosis of the 
lung, fibroid phthisis). Fourth: Severe and prolonged muscular 
exertion (athlete's heart). 

In valvular disease the greatest degree of hypertrophy is to be 
seen usually in relatively young persons, and especially when the 
advance of the lesion is not very rapid. 

Hypertrophy of the heart in valvular disease is also influenced 
by the amount of muscular work done by the patient, by the de- 
gree of vascular tension, and by the treatment. In the great major- 
ity of cases of hypertrophy, from whatever cause, both sides of the 
heart are affected, but we may distinguish cases in which one or the 
other ventricle is predominantly affected. 



206 PHYSICAL DIAGNOSIS. 

(1) Cardiac hypertrophy affecting especially the left ventricle. 

(a) The apex impulse is usually lower than normal, often in 
the sixth space, occasionally in the seventh or eighth. 1 It is also 
farther to the left than normal, but far less so than in cases in 
which the hypertrophy affects especially the right ventricle. The 
area of visible pulsation is usually increased, and a considerable por- 
tion of the chest wall may be seen to move with each systole of the 
heart, while frequently there is a systolic retraction of the inter- 
spaces in place of a systolic impulse. 

(b) Palpation confirms the results of inspection and shows us 
also that the apex impulse is unusually powerful. Percussion 
shows in many cases that the cardiac dulness is more intense and 
its area increased downward and to a lesser extent toward the left. 2 

(c) If we listen in the region of the maximum cardiac impulse, 
we generally hear an unusually long and low-pitched first sound, 
which may or may not be of a greater intensity than normal. A 
very loud first sound is much more characteristic of a cardiac neu- 
rosis than of pure hypertrophy of the left ventricle. 

The second sound at the apex (the aortic second sound trans- 
mitted) is usually much louder and sharper than usual. Ausculta- 
tion in the aortic area shows that the second sound at that point is 
loud and ringing in character. Not infrequently the peripheral ar- 
teries (the subclavians, brachials, carotids, radials, and femorals) 
may be seen to pulsate with each sj^stole of the heart. This sign is 
most frequently observed in cases of hypertrophy of the left ven- 
tricle, which are due to aortic regurgitation, but is by no means 
peculiar to this disease and may be repeatedly observed when the 
cardiac hypertrophy is due to nephritis or muscular work. I have 
frequently observed it in athletes, blacksmiths, and others whose 
muscular work is severe. 

The radial pulse wave has no constant characteristics, but de- 

1 This is due partly to a stretching of the aorta, .produced by the increased 
weight of the heart. 

-Post mortem hypertrophy of the left ventricle is often found despite the 
absence of the above signs in life. 



Valvular lesions. 207 

pends rather upon the cause which has produced the hypertrophy 
than upon the hypertrophy itself . 

(2) Cardiac Hypertrophy Affecting Especially the Right Ventricle. 

It is much more difficult to be certain of the existence of en- 
largement of the right ventricle than of the left. Practically we 
have but two reliable physical signs : 

(a) Increase in the transverse diameter of the heart, as shown 
by the position of the apex impulse and by percussion of the right 
and left borders of the heart ; and 

(b) Accentuation of the pulmonic second sound, which is often 
palpable as well as audible. 

The apex beat is displaced both to the left and downward, but 
especially to the left. In cases of long-standing mitral disease, the 
cardiac impulse may be felt in mid-axilla, several inches outside the 
nipple, and yet not lower down than the sixth intercostal space. 
In a small percentage of cases (i.e., when the right auricle is en- 
gorged), an increased area of dulness to the right of the sternum 
may be demonstrated. Accentuation of the pulmonic second sound 
is almost invariably present in hypertrophy of the right ventricle, 
though it is not peculiar to that condition. It may be heard, for 
example, in cases of pneumonia when no such hypertrophy is pres- 
ent, but in the vast majority of cases of cardiac disease we may 
infer the presence and to some extent the amount of hypertrophy 
of the right ventricle from the presence of a greater or lesser ac- 
centuation of the pulmonic second sound. The radial pulse shows 
nothing characteristic of this type of hypertrophy. 

Epigastric pulsation gives us no evidence of the existence of 
hypertrophy of the right ventricle, despite contrary statements in 
many text-books. Such pulsation is frequently to be seen in per- 
sons with normal hearts, and is frequently absent when the right 
ventricle is obviously hypertrophied. It is perhaps most often due 
to an unusually low position of the whole heart. 



208 



PHYSICAL DIAGNOSIS. 



Dilatation op the Heart. 

(1) Acute Dilatation. — Immediately after severe muscular exer- 
tion, as, for example, at the finish of a boat race, or of a two-mile 
run (especially in persons not properly trained), an acute dilatation 
of the heart may occur, and in debilitated or poorly nourished sub- 
jects such an acute dilatation may be serious or even fatal in its 
results. 

(2) Chronic dilatation comes on gradually as a result of valvu- 




Fig. 119. -Dilated Heart. From v. Ziemssen's Atlas. 



lar disease or other cause, and gives rise to practically the same 
physical signs as those of acute dilatation, from which it differs 
chiefly as regards the accompanying physical phenomena and the 
prognosis. Briefly stated, the signs of dilatation of the heart, 
whether acute or chronic, are : 

(a) Feebleness and irregularity of the apex impulse and of the 
radial impulse, (b) enlargement of the heart, as indicated by inspec- 
tion, palpation, and percussion, and (sometimes) (c) murmurs indi- 
cative of stretching of one or another of the valvular orifices. 



VALVULAR LESIONS. 209 



Dilatation of the Left Ventricle. 

Inspection shows little that is not better brought out by palpa- 
tion. Palpation reveals a " napping " cardiac impulse, or a vague 
shock displaced both downward and to the left and diffused over 
an abnormally large area of the chest wall. Percussion verifies 
the position of the cardiac impulse and sometimes shows an unusu- 
ally blunt or rounded outline at the apex of the heart. 

On auscultation, the first sound is usually very short anal shai'jo, 
but not feeble unless it is accompanied by a murmur. In case the 
mitral orifice is so stretched as to render the valve incompetent, or 
in case the muscles of the heart are so fatigued and weakened that 
they do not assist in closing the mitral orifice, a systolic murmur is 
to be heard at the apex of the heart. This murmur is transmitted 
to the axilla and back, but does not usually replace the first sound 
of the heart. The aortic second sound, as heard in the aortic area 
and at the apex, is feeble. 

Dilatation of the right ventricle of the heart is manifested by an 
increase in the area of cardiac dulness to the right of the sternum 
(corresponding to the position of the right auricle), by feebleness of 
the pulmonic second sound together with signs of congestion and 
engorgement of the lungs, and often by a systolic murmur at the 
tricuspid valve; i.e., at or near the root of the ensiform cartilage. 
When this latter event occurs, one may have also systolic pulsation 
in the jugular veins and in the liver (see below, p. 248). 

In cases of acute dilatation, such as occur in infectious fevers 
or at the end of well-contested races, there is often to be heard a 
systolic murmur loudest in the pulmonary area and due very pos- 
sibly to a dilatation of the conus arteriosus. 

The diagnosis of dilatation of the heart seldom rests entirely 
upon physical signs referable to the heart itself. In acute cases 
our diagnosis is materially aided by a knowledge of the cause, 
which is often tolerably obvious. In chronic cases the best evi- 
dence of dilatation is often that furnished by the venous stasis 
which results from it. 

14 



210 PHYSICAL DIAGNOSIS. 

(4) CHRONIC VALVULAR DISEASE. 
I. Mitral Kegurgitatio^. 

The commonest and on the whole the least serious of valvular 
lesions is incompetency of the mitral. It results in most cases 
from the shortening, stiffening, and thickening of the valve pro- 
duced by rheumatic endocarditis in early life. It is the lesion pres- 
ent in most cases of chorea (see Figs. 120 and 121). 

Temporary and curable mitral regurgitation may result from 
weakening of the heart muscle, which normally assists in closing 
the mitral orifice through the sphincter-like contraction of its cir- 
cular fibres. 

Great muscular fatigue, such as is produced by a hard boat 
race, may result in a temporary relaxation of the mitral sphincter 
or of the papillary muscles sufficient to allow of genuine but tem- 
porary and curable regurgitation through the mitral orifice. In 
conditions of profound nervous debility, excitement, or exhaustion, 
similar weakening of the cardiac muscles may allow of a leakage 
through the mitral, which ceases with the removal of its cause. 
Stress has been laid upon these points by Prince, and recently by 
Arnold. 

Mitral insufficiency due to stretching of the ring into which the 
valve is inserted occurs not unfrequently as a result of dilatation 
of the left ventricle, and is commonly known as relative insufficiency 
of the mitral valve. The valve orifice can enlarge, the valve can- 
not, and hence its curtains are insufficient to fill up the dilated ori- 
fice. This type of mitral insufficiency frequently results from 
aortic regurgitation with the dilatation of the left ventricle which 
that lesion produces, or from myocarditis, which weakens the heart 
wall until it dilates and widens the mitral orifice. 

The results of any form of mitral leakage occur in this order : 

1. Dilatation or hypertrophy of the left auricle, which has to 
receive blood both from the lungs and through the leaky mitral 
from the left ventricle. 

2. The overfilled left auricle cannot receive the blood from the 



VALVULAR LESIONS. 



211 



lungs as readily as it should; hence the blood "backs up" in the 
lungs and thereby increases the work which the right ventricle 
must do in order to force the blood through thern. Thus result 
oedema of the lungs, and — 










Fig. 120. 







Vjeasa/Jft#a/> 



Fig. 121. 

FIG. 120.— Normal Heart during Systole. Mitral valve closed ; blood flowing through the open 
aortic valves into the aorta. 

Fig. 121.— Mitral Regurgitation. The heart is in systole and the arrows show the current flowing 
back in the left auricle as well as forward into the aorta. 



212 PHYSICAL DIAGNOSIS. 

(3) Hypertrophy and dilatation of the right ventricle, which in 
turn becomes sooner or later overcrowded so that the tricuspid 
valve gives way and tricuspid leakage occurs. 

(4) The capacity for hypertrophy possessed by the right auricle 
is soon exhausted, and we get then — 

(5) General venous stasis, which shows itself first as venous 
pulsation in the jugulars and in the liver and later in the tissues 
drained by the portal and peripheral veins. This venous stasis in- 
creases the work of the left ventricle, and so we get — 

(6) Hypertrophy and dilatation of the left ventricle. Hyper- 
trophy of the left ventricle is also produced by the increased work 
necessary to maintain some vestige of sphincter action at the leaky 
mitral orifice, as well as by the labor of contracting upon the extra 
quantity of blood delivered to it by the enlarged left auricle. 

At last the circle is complete. Every chamber in the heart is 
enlarged, overworked, and failure is imminent. 

Returning now to the signs of mitral regurgitation, we shall find 
it most convenient to consider first the type of regurgitation pro- 
duced by rheumatism and resulting in thickening, stiffening, and 
retraction of the valve. 

Physical Signs. 

(a) First Stage — Prior to the Establishment of Compensation. 

We have but one characteristic physical sign : 

A systolic murmur heard loudest at the apex of the heart, trans- 
mitted to the back (below or inside the left scapula) and to the left 
axilla. The murmur is not infrequently musical in character, and 
when this is the case diagnosis is much easier. Systolic musical 
murmurs so transmitted do not occur without valvular leakage. 
Eosenbach believes that adherent pericardium is capable of produc- 
ing such a murmur, but only, if I understand him rightly, in case 
there is a genuine mitral leakage due to the embarrassing embrace 
of the pericardium which prevents the mitral orifice from closing. 

"Functional" or "hsemic" murmurs are rarely heard in the 
back, and very rarely, if ever, have a musical quality. 



VALVULAR LESIONS. 213 

Cases of mitral regurgitation are not very often seen at this 
stage, but in acute endocarditis after the fever and anaemia have 
subsided, or in chorea, such a murmur may exist for days or weeks 
before any accentuation of the pulmonic second sound or any en- 
largement of the heart appears. I have had the opportunity of 
verifying the diagnosis at autopsy in two such cases. 

(b) Second Stage — Compensation Established. 

As long as compensation remains perfect, the only evidence of 
regurgitation may be that obtained by auscultation, and I shall 
accordingly begin with this rather than in the traditional way with 
inspection, palpation, and percussion. 

The distinguishing auscultatory phenomena in cases of well- 
compensated mitral insufficiency are : 

(a) A systolic murmur whose maximum intensity is at or near 
the apex impulse of the heart, but which is also to be heard in the 
left axilla and in the back below or inside the angle of the left 
scapula (so far the signs are those of the first stage, above de- 
scribed). 

(b) A pathological accentuation of the pulmonic second sound. 
This is the minimum of evidence upon which it is justifiable to 

make the diagnosis of compensated mitral regurgitation. In the 
vast majority of cases, however, our diagnosis is confirmed by the 
following additional data: 

(c) Enlargement of the heart as shown by inspection, palpation, 
and percussion. 

The pulse in well-compensated cases shows no considerable 
abnormality. When compensation begins to fail, or sometimes be- 
fore that time, the most characteristic thing about the pulse is its 
marked irregularity both in force and rhythm. Such irregularity 
is at once more common and less serious in mitral disease than in 
that of any other valve ; it may continue for years and be compat- 
ible with very tolerable health. 



214 



PHYSICAL DIAGNOSIS. 



Eeturning now to the details of the sketch just given, we will 
take up first — 

(a) The Murmur. — In children the murmur of mitral regurgita- 
tion may be among the loudest of all murmurs to be heard in val- 



lst 



I 



2nd 



ii 



1st 



I 



2nd. 



J_L 



Fig. 122.— Diagram to Represent Systolic Mitral Murmur. The heavy lines represent the normal 
cardiac sounds and the light lines the murmur, which in this case does not replace the first 
sound and '• tapers " off characteristically at the end. 

vular disease, but this does not necessarily imply that the lesion is 
a very severe one. A murmur which groivs louder under observa- 
tion in a well-compensated valvular lesion may mean an advance of 
the disease, but if the case is first seen after compensation has 
failed a faint, variable whiff in the mitral area may mean the se- 
verest type of lesion. As the patient improves under the influence 
of rest and cardiac tonics, such a murmur may grow very much 
louder, or a murmur previously inaudible may appear. 

The length of the murmur varies a great deal in different cases 
and is not of any great practical importance. It rarely ends 
abruptly, but usually "tails off " at the end of systole (see Fig. 122). 
Musical murmurs are heard more often in mitral regurgitation than 
in any other valve lesion, but the musical quality rarely lasts 
throughout the whole duration of the murmur, contrasting in this 
respect with musical murmurs produced at the aortic valve. The 



2nd 



UN ■ ■ I 



2nd 



ll illfi i , I 



Fig. 123.— Systolic Mitral Murmur Replacing the First Sound of the Heart. 



first sound of the heart may or may not be replaced by the murmur 
(see Fig. 123). When the sound persists and is heard either with 
or before the murmur, one can infer that the lesion is relatively 
slight in comparison with cases in which the first sound is wholly 



VALVULAR LESIONS. 



215 



obliterated. Post-systolic or late systolic murmurs, which are occa- 
sionally heard in mitral regurgitation, are said to point to a rela- 
tively slight amount of disease in the valve (see Fig. 122). Rosen- 



lst 



I 



2nd 



1st 



1 



2nd 



Fig. 124.— Late Systolic Murmur. The first sound is clear and an interval intervenes between 

it and the murmur. 

bach claims that the late systolic murmur is always due to organic 
disease of the valves and never occurs as a functional murmur. 

When compensation fails, the murmur may altogether disappear 
for a time, and if the patient is then seen for the first time and 
dies without rallying under treatment, it may be impossible to 




Pulmonic second 
accented. 



Systolic murmur 
loudest here. 



Fig. 125.— Mitral Regurgitation. 



The murmur is heard over the shaded area as well as in the 
back. 



make the diagnosis. The very worst cases, then, are those in which 
there is no murmur at all. 

The murmur of mitral regurgitation is conducted in all directions, 
but especially toward the axilla and to the back {not around the 
chest, but directly). In the latter situation it is usually louder 



216 



PHYSICAL DIAGNOSIS. 



than it is in mid-axilla, and occasionally it is heard as loudly in the 
back as anywhere else. This is no doubt owing to the position of 
the left auricle (see Figs. 125 and 126). 

(b) After compensation is established and as long as it lasts an 
accentuation of the pulmonic second sound is almost invariably to 
be made out, and may be so marked that we can feel and see it, as 
well as hear it. Not infrequently one can also see and feel the 
pulsation of the conus arteriosus — not the left auricle— in the second 
and third left intercostal space. (It may be well to mention again 



Systolic murmur. 




Fig. 126.— Mitral Regurgitation. Murmur heard over the shaded area. 



here that by accentuation of the pulmonic second sound one does 
not mean merely that it is louder or sharper in quality than the 
aortic second sound, since this is true in the vast majority of cases 
in healthy individuals under thirty years of age. Pathological ac- 
centuation of the pulmonic second sound means a greater intensity 
of the sound than we have a right to expect at the age of the individ- 
ual in question.) Occasionally the pulmonic second sound is redu- 
plicated, but as a rule this points to an accompanying stenosis of 
the mitral valve. At the apex the second sound {i.e., the trans- 
mitted aortic second) is not infrequently wanting altogether, owing 



VALVULAR LESIONS. 217 

to the relatively small amount of blood which recoils upon the 
aortic ,r alves. 

(n) Enlargement of the heart, and more especially of the right 
ventricle, is generally to be made out, and in the majority of cases 
this enlargement is manifested by displacement of the apex impulse 
both downward and toward the left, but more especially to the 
left. Percussion confirms the results of inspection and palpation 
regarding the position of the cardiac impulse. The normal sub- 
sternal dulness is increased in intensity, and we can sometimes 
demonstrate an enlargement of the heart toward the right (see 
Fig. 123). 

In children (in whom adhesive pericarditis often complicates 
the disease) a systolic thrill may not infrequently be felt at the 
apex, and the precordia may be bulged, and even in adults such a 
systolic thrill is not so rare as some writers would have us sup- 
pose. 

(d) The pulse, as said above, shows nothing characteristic at any 
stage of the disease. While compensation lasts, there is usually 
nothing abnormal about the pulse, although it may be somewhat 
irregular in force and rhythm, and may be weak when compared to 
the powerful beat at the apex in case the regurgitant stream is a 
very large one. Irregularity at this period is less common in pure 
mitral regurgitation than in cases complicated by stenosis. 

(c) Third Stage — Failing Compensation. 

When compensation begins to fail, the pulse becomes weak and 
irregular, and many heart beats fail to reach the wrist, but there 
is still nothing characteristic about the pulse, which differs in no 
respect from that of any case of cardiac weakness of whatever 
nature. 

(e) Evidence of venous stasis, first in the lungs and later in the 
liver, lower extremities, and serous cavities, does not show itself 
so long as compensation is sufficient, but when the heart begins to 
fail the patient begins to complain not only of palpitation and car- 
diac distress, but of dyspnoea, orthopncea, and cough, and examina- 
tion reveals a greater or lesser degree of cyanosis with pulmo- 



218 PHYSICAL DIAGNOSIS 

nary oedema manifested by crackling rales at the base of the lungs 
posteriorly, and possibly also by haemoptysis or by evidences of 
hydrothorax (see below, p. 330 j. If compensation is not re-estab- 
lished, the right ventricle dilates, the tricuspid becomes incompe- 
tent, the liver becomes enlarged and tender, dropsy becomes gen- 
eral, the heart and pulse become more and more rapid and irregular, 
the heart murmur disappears and is replaced by a confusion of 
short valvular sounds, "gallop rhythm'''' or "delirium cordis ," often 
considerably obscured by the noisy, labored breathing with numer- 
ous moist rales. In a patient seen for the first time in such a con- 
dition diagnosis may be impossible, yet mitral disease of some type 
may usually be suspected, since murmurs produced at the aortic 
valve are not so apt to disappear when compensation fails. The 
relative tricuspid insufficiency which often occurs is likely to mani- 
fest itself by an enlargement of the right auricle, sometimes demon- 
strable by percussion and later by venous pulsation in the neck and 
in the liver. 

(d) Differential Diagnosis. 

The murmur of mitral regurgitation may be confused with 

(1) Tricuspid regurgitation. 

(2) Functional murmurs. 

(3) Stenosis or roughening of the aortic valves. 

(1) The post-mortem records of the Massachusetts General 
Hospital show that in the presence of a murmur due to mitral re- 
gurgitation it is very easy to fail altogether to recognize a tricuspid 
regurgitant murmur. Only 5 out of 29 cases of tricuspid regurgi- 
tation found at autopsy were recognized during life. Allbutt's 
figures from Guy's Hospital are similar. In the majority of these 
cases, mitral regurgitation was the lesion on which attention was 
concentrated during the patient's life. This is all the more excus- 
able because the tricuspid area is so wide and uncertain. Murmurs 
produced at the tricuspid orifice are sometimes heard with maxi- 
mum intensity just inside the apex impulse, and if we have also a 
mitral regurgitant murmur, it may be impossible under such cir- 
cumstances to distinguish it from the tricuspid murmur. Some- 



VALVULAR LESIONS. 219 

times the two are of different pitch, but more often tricuspid regur- 
gitation must be recognized indirectly if at all, i.e., through the 
evidence given by venous pulsation in the jugular veins and in the 
liver. Tricuspid murmurs are not transmitted to the left axilla 
and do not cause accentuation of the pulmonic second sound, al- 
though they are compatible with such accentuation. They are to 
be distinguished from the murmurs of mitral regurgitation by their 
different seat of maximum intensity, possibly by a difference in 
pitch, but most clearly by the concomitant phenomena of venous 
pulsation above mentioned. 

(2) " Functional " murmurs are usually systolic and may have 
their maximum intensity at the apex of the heart, but in the great 
majority of cases they are heard best over the pulmonic valve or 
just inside or outside the apex beat (Potain). They are faint or 
inaudible at the end of expiration, and are more influenced by 
position than organic murmurs are. In the upright position they 
are often very faint. They are rarely transmitted beyond the 
precordia and are unaccompanied by any evidences of enlargement 
of the heart, by any pathological accentuation of the pulmonic 
second sound, 1 or any evidences of engorgement of the lungs or 
general venous system. 

(3) Roughening or narrowing of the aortic valves may produce 
a systolic murmur with maximum intensity in the second right in- 
tercostal space, but this murmur is not infrequently heard all over 
the precordia and quite plainly at the apex, so that it may simulate 
the murmur of mitral regurgitation. The aortic murmur may in- 
deed be heard more plainly at the apex than at any other point ex- 
cept the second right intercostal space, owing to the fact that the 
right ventricle, which occupies most of the precordial region be- 
tween the aortic and mitral areas, does not lend itself well to the 
propagation of certain types of cardiac murmurs. Under these 
circumstances " a loud, rough aortic murmur may be heard at the 

1 It must be remembered that in chlorosis, a disease in which functional 
murmurs are especially prone to occur, the pulmonic second sound is often 
surprisingly loud, owing to a retraction of the left lung, which uncovers the 
root of the pulmonic artery. 



220 PHYSICAL DIAGNOSIS. 

apex as a smooth murmur of a different tone " (Broadbent) . Such 
a murmur is not, however, likely to be conducted to the axilla or 
heard beneath the left scapula, nor to be accompanied by accentua- 
tion of the pulmonic second sound nor evidences of engorgement 
of the lungs and general venous system. 

II. Mitral Stenosis. 

Narrowing or obstruction of the mitral orifice is almost invari- 
ably the result of a chronic endocarditis which .gradually glues to- 
gether the two flaps of the valve until only a funnel-shaped open- 
ing or a slit like a buttonhole is left see Figs. ( 127 and 128). As we 
examine post mortem the tiny slit which may be all that is left of 
the mitral orifice in a case of long standing, it is difficult to con- 
ceive how sufficient blood to carry on the needs of the circulation 
could be forced through such an insignificant opening. 

Usually a slow and gradually developed lesion, mitral stenosis 
often represents the later stages of a process which in its earlier 
phases produced pure mitral regurgitation. By some observers the 
advent of stenosis is regarded as representing an attempt at com- 
pensation for a reduction of the previous mitral leakage. Others 
consider that the stenosis simply increases the damage which the 
valve has suffered. 

A remarkable fact never satisfactorily explained is the predilec- 
tion of mitral stenosis for the female sex. 1 A large proportion of 
the cases — seventy-six per cent in my series — occur in women. 

It is also curious that so many cases are associated with pul- 
monary tuberculosis. 

Physical Signs. 

Mitral stenosis may exist for many years without giving rise to 
any physical signs by which it may be recognized, and even after 
signs have begun to show themselves they- are more fleeting and 
inconstant than in any other valvular lesion of the heart. In the 
early stages of the disease the heart may appear to be entirely nor- 

1 Fenwick's explanation, viz., that the sedentary life of women favors 
the slow adhesive inflammation of the valve and its curtains, resulting in 
stenosis, does not seem to me to be satisfactory. 



VALVULAR LESIONS. 



221 



mal if the patient is at rest, and especially if examined in the re- 
cumbent position, characteristic signs being elicited only by exer- 
tion ; or again a murmur which is easily audible with the patient 
in the upright position may disappear in the recumbent position ; 
or a murmur may be heard at one visit, at the next it may be im- 







.jS7e/ea*t?Jfs/&2/> 



Fig. 123. 



Fig. 127.— Diagram to Represent the Position of the Valves in the Normal Heart during Diastole, 
the Open Mitral Allowing the Blood to Flow Down from the Left Auricle, the Aortic Closed. 

Fig. 128.— Mitral Stenosis— Period of Diastole. The blood flowing from the left auricle is ob- 
structed by the thickened and adherent mitral curtains. 



222 



PHYSICAL DIAGNOSIS. 



passible to elicit it by any manoeuvre, while at the third visit it may 
be easily heard again. These characteristics explain to a certain 
extent the fact that differences of opinion so often arise regarding 
the diagnosis of mitral stenosis, and that out of forty-eight cases in 
which this lesion was found at autopsy at the Massachusetts General 
Hospital, only twenty-three were recognized during life. No com- 
mon lesion (with the exception of tricuspid regurgitation) has been 
so frequently overlooked in our records. 

I shall follow Broadbent in dividing the symptoms into three 
stages, according to the extent to which the lesion has progressed. 

I. 

In the first stage inspection and palpation show that the apex 
beat is little if at all displaced, and percussion reveals no increase 




Pulmonic second 



" Double- shock ' 
sound. 



Presystolic murmur 
heard in limited 



Fig. 129— Mitral Stenosis. 



in the area of cardiac dulness ; indeed, in rare cases the heart may 
be smaller than usual. If one lays the hand lightly over the origin 
of the apex beat, one can generally feel the purring presystolic thrill 
which is so characteristic of this disease, more common indeed than 
in any other. This thrill is more marked in the second stage of 
the disease, but can generally be appreciated even in the first. It 
runs up to and ceases abruptly with the very sharp first sound, 



VALVULAR LESIONS. 223 

the sudden shock of which, may be appreciated even by palpation. 
The thrill is sometimes palpable even when no murmur can be 
heard, and often the thrill is transmitted to the axilla when the 
murmur is confined to the apex region. On auscultation one 
hears, especially after the patient has been exerting himself, and 
particularly if he leans forward and to the left, a short low-pitched 
rumble or roll immediately preceding the systole and increasing 
in intensity as it approaches the first sound. At this stage of 
the disease the second sound can still be heard at the apex. The 
first sound is very sharply accented or snapping, and communi- 
cates a very decided shock to the ear when a rigid stethoscope 
is used. As a rule, the murmur is closely confined to the region 
of the apex beat and not transmitted any considerable distance in 
any direction. I have seen cases in which it was to be heard only 

1st 







2nd ...ill I 2nd 



Fig. 130.— The Murmur of Mitral Stenosis— First Stage. The place of the murmur and its cres- 
cendo character are indicated by the position of the light lines just before the first sound 
and by their increasing length. 

over an area the size of a half-dollar. 1 Very characteristic of mi- 
tral stenosis is a prolongation of the diastolic pause so that the inter- 
val beween the second sound of one cycle and the first sound of the 
next is unduly long. Occasionally the diastolic sound is redupli- 
cated (" double-shock sound " — Sansom) at this stage of the disease, 
but this is much more frequent in the later phases of the lesion. 2 

Irregularity of the heart beat both in force and rhythm is very 
frequently present even in the early stages of the affection. The 
heart may be regular while the patient is at rest, but slight exer- 
tion is often sufficient to produce marked irregularity. 

1 It may, however, be widely transmitted to the left axilla and audible in 
the back or even over the whole of the left chest, especially when the stenosis 
is combined with regurgitation. 

2 This is the opinion of most observers. Sansom states that the "double- 
shock sound" may precede all other evidences of mitral stenosis. 



224 PHYSICAL DIAGNOSIS. 

II. 

In the second stage the murmur and thrill are usually longer and 
may occupy th whole of diastole, beginning with considerable in- 
tensity just after the reduplicated second sound, quickly dhninish- 

lst 1st 



...Mini 



I in 1 11 i 1 1 iiiillllll 



Fig. 131.— Type of Presystolic Murmur Often Heard in the Second Stage of Mitral Stenosis. 
Here the murmur fills the whole of diastole, with a gradual increase of intensity as it ap- 
proaches the first sound. No second sound is audible at the apex. 

ing until it is barely audible, and then again increasing with a 
steady crescendo up to the first sound of the next cycle. 1 These 
changes may be graphically represented as in Figs. 130 and 131. Dia- 
stole is now still more prolonged, so that the characteristic rhythm 
of this lesion is even more marked than in the earlier stages of the 
disease. In many cases at this stage no second sound is to be heard 
at all at the apex, although at the pulmonic orifice it is loud and 
almost invariably double. (This is one of the reasons for believing 
that the second sound which we usually hear at the apex is the 
transmitted aortic second sound. In mitral disease the aortic valves 

1st 



,11 



lln MiililllM li 



Fig, 132.— Type of Presystolic Murmur Sometimes Heard in the Second Stage of Mitral Stenosis. 
There is a double crescendo. The second sound seems reduplicated. 

shut feebly owing to the relatively small amount of blood that is 
thrown into the aorta.) 

At this stage of the disease enlargement of the heart begins to 
make itself manifest. The apex impulse is displaced to the left — 

1 Rarely one finds a crescendo in the middle of a long presystolic roll with 
a diminuendo as it approaches the first sound. 



VALVULAR LESIONS. 225 

sometimes as far as the mid-axillary line, and often descends to 
the sixth interspace. Occasionally the cardiac dnlness is increased 
to the right of the sternnm. 

The instability and fleeting character of the murmur in the ear- 
lier stages of the disease are much less marked in this, the second 
stage. The first sound at the apex still retains its sharp, thump- 
ing quality, and is often audible without ths murmur in the back. 

The irregularity of the heart is generally greater at this stage 
than in the earlier one. 

III. 

The third stage of the affection is marked by the disappearance 
of the characteristic murmur, and is generally synchronous with 
the development of tricuspid regurgitation. The right ventricle 
becomes dilated sometimes very markedly. Indeed, it may produce 
a visible pulsating tumor below the left costal border and be mis- 
taken for cardiac aneurism (Osier). The snapping first sound and 
the " double-shock " sound usually remain audible, but the latter 
may be absent altogether. Diagnosis in this stage rests largely upon 
the peculiar snapping character of the first sound, together with the 
prolongation of diastole and the very great irregularity of the heart, 
both in force and rhythm. At times a presystolic thrill may be 
felt even when no murmur is to be heard. 

The pulse shows nothing characteristic in many cases except 
that early and persistent irregularity which has been already al- 
luded to. In other cases the wave is low, long, easily compressed, 
but quite perceptible between beats ; but for the lack of sufficient 
power in the cardiac contractions the pulse would be one of high 
tension. 

As the disease advances the irregularity of the pulse becomes 
more and more marked, and sometimes presents an amazing contrast 
with the relatively good general condition of the circulation. Even 
when not more than a third of the beats reach the wrist, the patient 
may be able to attend to light work and feel very well. Such cases 
make us feel as if a pulse were a luxury rather than a necessity. 

Under the influence of digitalis the pulse is especially apt to 
15 



226 PHYSICAL DIAGNOSIS. 

assume the bigeminal type in mitral stenosis. Every other beat is 
then so abortive that it fails to send a wave to the wrist, and the 
weak beat is succeeded by a pause. According to Broadbent the 
weak beat corresponds to an abortive contraction of the left ven- 
tricle accompanied by a normal contraction of the right ventricle, 
so that for each tivo strong beats of the right side of the heart we 
have one strong and one weak beat of the left side of the heart. 

Mitral stenosis is in the great majority of cases combined with 
mitral regurgitation, and it often happens that the signs of regur- 
gitation are so much more prominent than those of stenosis that 
the latter escape observation altogether, especially in the third 
stage of the disease, when the typical presystolic roll has disap- 
peared. In such cases combined stenosis and regurgitation is to be 
distinguished from pure regurgitation by the sharpness of the first 
sound, which would be very unusual at this stage of a case of pure 
mitral regurgitation. The presence of reduplicated second sound, a 
" double-shock sound " at the outset of the prolonged diastolic pause, 
and of great irregularity in force and rhythm, is further suggestive 
of mitral stenosis. 

Mitral stenosis is apt to be associated with haemoptysis, with en- 
gorgement of the liver and ascites, and especially with arterial em- 
bolism. No other valve lesion is so frequently found associated 
with embolism. The lungs are generally very voluminous, and 
may therefore mask an increase in area or intensity of the cardiac 
dulness. 

Differential Diagnosis. 

I have already discussed the difficulty of distinguishing a double 
lesion at the mitral valve from a simple mitral regurgitation (see 
above, p. 215). 

Other murmurs which may be mistaken for the murmur of mi- 
tral stenosis are : 

(a) The Austin Flint murmur. 

(b) The murmur of tricuspid stenosis. 

(c) A rumbling murmur sometimes heard in children, after an 
attack of pericarditis. 



VALVULAR LESIONS. 227 

(<z) The Austin Flint murmur. 

In 1862 Austin Flint studied two cases in which during life a 
typical presystolic roll was audible at the apex of the heart, yet in 
which post mortem the mitral valve proved to be perfectly normal, 
and the only lesion present was aortic insufficiency. This observation 
has since been verified by Osier, Bramwell, Gairdner, and other com- 
petent observers. At the Massachusetts General Hospital we have 
had seven such cases with autopsy. Yet, despite repeated confir- 
mation, Flint's observation has remained for nearly forty years un- 
known to physicians at large. Its importance is this : Given a case 
of aortic regurgitation — a presystolic murmur at the apex does not 
necessarily mean stenosis of the mitral valve even though the mur- 
mur has the typical rolling quality and is accompanied by a pal- 
pable thrill. It may be only one of the by-effects of the aortic 
incompetency. How it is that a presystolic murmur can be pro- 
duced at the apex in cases of aortic regurgitation has been much 
debated. Some believe it is due to the impact of the aortic regur- 
gitant stream upon the ventricular side of the mitral valve, floating 
it out from the wall of the ventricle so as to bring it into contact 
with the stream of blood descending from the left auricle. Others 
suppose that the mingling of the two currents of blood, that from 
the mitral and that from the aortic orifice, is sufficient to produce 
the murmur. 

Between the " Austin Flint murmur " thus denned and the mur- 
mur of true mitral stenosis, complicating aortic regurgitation, diag- 
nosis may be impossible. If there are no dilatation of the mitral 
orifice and no regurgitation, either from this cause or from deformi- 
ties of the mitral valve itself, any evidence of engorgement of the 
pulmonary circuit (accentuation of the pulmonic second sound, 
oedema of the lungs, haemoptysis, and cough) speaks in favor of an 
actual narrowing of the mitral valve, while the absence of such 
signs and the presence of a predominating hypertrophy of the left 
ventricle tend to convince us that the murmur is of the type de- 
scribed by Austin Flint, i.e., that it does not point to any sten- 
osis of the mitral valve. The sharp, snapping first sound and 
systolic shock so characteristic of mitral stenosis are said to be 



228 PHYSICAL DIAGNOSIS. 

modified or absent in connection with murmurs of the Austin Flint 
type. 

(b) Tricuspid obstruction. 

Luckily for us as diagnosticians, stenosis of the tricuspid valve 
is a very rare lesion. Like mitral stenosis it is manifested by a 
presystolic rolling murmur whose point of maximum intensity is 
sometimes over the traditional tricuspid area, but may be at a point 
so near the mitral area as to be easily confused with stenosis of 
the latter valve. 

The difficulty of distinguishing tricuspid stenosis from mitral 
stenosis is further increased by the fact that the two lesions almost 
invariably occur in conjunction. Hence we have two presystolic 
murmurs, perhaps with slightly different points of maximum inten- 
sity and possibly with a difference in quality, but often quite un- 
distinguishable from each other. In the vast majority of cases, 
therefore, tricuspid stenosis is first recognized at the autopsy, and 
the diagnosis is at best a very difficult one. 

(c) Broadbent, Rosenbach, and others have noticed in children 
who have just passed through an attack of pericarditis a rumbling 
murmur near the apex of the heart, which suggests the murmur of 
mitral stenosis. It is distinguished from the latter, however, by the 
absence of any accentuation of the first sound at the apex, as well 
as by the conditions of its occurrence and by its transiency. Such 
cases are important, since their prognosis is much more favorable 
than that of mitral stenosis. 

Phear (Lancet, September 21, 1895) investigated 46 cases in 
which a presystolic murmur was observed during life and no mitral 
lesion found at autopsy. In 17 of these there was aortic regurgi- 
tation at autopsy ; in 20 of these there was adherent pericardium 
at autopsy ; in 9 nothing more than dilatation of the left ventricle 
was found. In none of these cases was the snapping first sound, 
so common in mitral stenosis, recorded during life. 

It should be remembered that patients suffering from mitral 
stenosis are very frequently unaware of any cardiac trouble, and 
seek advice for anaemia, wasting, debility, gastric or pulmonary 
complaints. This is less often true in other forms of valvular dis- 



VALVULAR LESIONS. 229 

ease. We should be especially on our guard in cases of supposed 
"nervous arrhythmia" or "tobacco heart/' if there has been an at- 
tack of rheumatism or chorea previously. Such cases may present 
no signs of disease except the irregularity— yet may turn out to 
be mitral stenosis. 

IY. Aortic Regurgitation. 

Rheumatic endocarditis usually occurs in early life and most 
often attacks the mitral valve. The commonest cause of aortic dis- 
ease on the other hand — arterio-sclerosis — is a disease of late mid- 




Mt/ta/ fa/z/> 



Fig. 133.— Diastole in Aortic Regurgitation. The blood is flowing back through the stumpy and 
incompetent aortic valves. 

die life, and attacks men much more often than women. When 
we think of aortic regurgitation, the picture that rises before us is 
usually that of a man past middle life and most often from the 
classes who live by manual labor. Nevertheless cases occur at all 
ages and in both sexes, and rheumatic endocarditis does not spare 
the aortic cusps altogether by any means. 

Whether produced by arterio-sclerosis extending down from the 
aorta, or by rheumatic or septic endocarditis, the lesion which re- 
sults in aortic regurgitation is usually a thickening and shortening 
of the cusps (see Fig. 133). In rare cases an aortic cusp may be 
ruptured as a result of violent muscular effort, and the signs and 



230 PHYSICAL DIAGNOSIS. 

symptoms of regurgitation then appear suddenly. But as a rule 
the lesion comes on slowly and insidiously, and unless discovered 
accidentally or in the course of routine physical examination it may 
exist unnoticed for years. Dropsy and cyanosis are relatively late 
and rare, and the symptoms which first appear are usually those of 
dyspnoea and precordial distress. 

It is a disputed point whether relative and temporary aortic 
insufficiency due to stretching of the aortic orifice ever occurs. If 
it does occur, it is certainly exceedingly rare, as the aortic ring is 
very tough and inelastic. 

Dilatation of the aortic arch — practically diffuse aneurism — oc- 
curs in almost every case of aortic regurgitation, and produces sev- 
eral important physical signs. This complication is a very well- 
known one, but has not, I think, been sufficiently insisted on in 
text-books of physical diagnosis. It forms part of that general 
enlargement of the arterial tree which is so characteristic of the 
disease. 

Physical Signs. 

Inspection reveals more that is important in this disease than 
in any other valvular lesion. In extreme cases the patient's face 
or hand may blush visibly with every systole. Not infrequently 
one can make the diagnosis across the room or in the street by not- 
ing the violent throbbing of the carotids, which may be such as to 
shake the person's whole head and trunk, and even the bed on 
which he lies. ISTo other lesion is so apt to cause a heaving of the 
whole chest and a bobbing of the head, and no other lesion so often 
causes a bulging of the precordia, for in no other lesion is the en- 
largement of the heart so great (cor bovinum or ox-heart). The 
throbbing of the dilated aorta can often be felt and sometimes seen 
in the suprasternal notch or in the second right interspace. Not 
only the carotids but the subclavians, the brachials and radials, 
the femoral and anterior tibial, and even the digital and dorsalis 
pedis arteries may visibly pulsate, and the characteristic jerking 
quality of the pulse may be seen as well as felt. This visible pul- 
sation in the peripheral arteries, while very characteristic of aortic 



VALVULAR LESIONS. 



231 



regurgitation, is occasionally seen in cases of simple hypertrophy of 
the heart from hard muscular work {e.g., in athletes). If the ar- 
teries are extensively calcined, their pulsation become much less 
marked. 

The peculiar conditions of the circulation whereby it is "changed 
into a series of discontinuous discharges as if from a catapult" (All- 
butt) throws a great tensile strain upon all the arteries, and results, 
in almost every long-standing case, in increasing both their length 



Pulsation at the jugulum. 



Dulness and pul- 
sation corre- 
sponding to the 
dilated aortic 
arch. 




Pulsating car- 
otids. 



Diastolic murmur. 



Displaced cardiac 
impulse. 



Fig. 134. 



-Aortic Regurgitation, Showing Position of the Diastolic Murmur and Areas of Visible 
Pulsation. 



and their diameter. The visible arterial trunks become tortuous 
and distended, while the arch of the aorta is diffusely dilated and 
becomes practically an aneurism (see Fig. 134). With each heart 
beat the snaky arteries are often jerked to one side as well as made 
to throb. 

Inspection of the region of the cardiac impulse almost always 
shows a very marked displacement of the apex beat both doivnward 
and outward (but especially the former), corresponding to the hy- 
pertrophy and still more to the dilatation of the left ventricle, 



232 PHYSICAL DIAGNOSIS. 

which is usually very great, and to the downward sagging of the 
enlarged aorta. Dilatation is in this disease an essentially helpful 
and compensatory process. In a small proportion of the cases no 
enlargement of the heart is to be demonstrated. This was true of 
5 out of the last 67 cases which I have notes of, and generally 
denotes an early and slight lesion. Not at all infrequently one 
finds a systolic retraction of the interspaces near the apex beat 
instead of a systolic impulse. This is probably due to the negative 
pressure produced within the chest by the powerful contraction of 
an liypertrophied heart. In the suprasternal notch one often feels 
as well as sees a marked systolic pulsation transmitted from the arch 
of the dilated aorta, and sometimes mistaken for saccular aneurism. 
Arterial pulsation of the liver and spleen are rarely demon- 
strable by a combination of sight and touch. 

Capillary Pulsation. 

If one passes the end of a pencil or other hard substance once 
or twice across the patient's forehead, and then watches the red 
mark so produced, one can often see a systolic flushing of the hyper- 
eemic area with each beat of the heart. This is by far the best 
method of eliciting this phenomenon. It may also be seen if a glass 
slide is pressed against the mucous membrane of the lip so as par- 
tially to blanch it, or if one presses upon the finger-nail so as par- 
tially to drive the blood from under it ; but in both these manoeuvres 
error may result from inequality in the pressure made by the ob- 
server upon the glass slide or upon the nail. Very slight movements 
of the observer's fingers, even such as are caused by his own pulse, 
may give rise to changes simulating capillary pulsation. Capillary 
pulsation of normal tissues is not often seen in any condition other 
than aortic 1 regurgitation, yet occasionally one meets with it in 
diseases which produce very low tension of the pulse, such as 
phthisis or typhoid, anaemic and neurasthenic conditions, and I 
have twice seen it in perfectly healthy persons. In such cases the 
pulsation is usually less marked than in aortic regurgitation. 
Rarely pulsation may be detected in the peripheral veins. 

1 Jumping toothache and throbbing felon are common examples of capil- 
lary pulsation in inflamed areas. 



VALVULAR LESIONS. 



233 



Palpation. 

Palpation verifies the position of the cardiac impulse and the 
of the whole chest wall suggested by inspection. The 
shock of the heart is very powerful and deliberate unless dilatation 



heaving 




Fig. 135.— Sphygmographic Tracing from Normal Pulse. 

is extreme, when it becomes wavy and diffuse. In the supraclavic- 
ular notch a systolic thrill is often to be felt. A diastolic thrill 
in the precordia is very rare. 

The pulse is important, usually characteristic. The wave rises 




FIG. 136.— Sphygmographic Tracing of the "Pulsus Celer" in Aortic Regurgitation. Its col- 
lapsing character is well shown. 

very suddenly and to an unusual height, then collapses completely 
and with great rapidity (pulsus celer) (see Figs. 135, 136). 

This type of pulse, which is known as the " Corrigan pulse " or 
"water-hammer pulse," is exaggerated if one raises the patient's 
arm above the head so as to make the force of gravity aid in emp- 
tying the artery. The quality of the pulse in aortic regurgitation 



234 PHYSICAL DIAGNOSIS. 

is due to the fact that a large volume of blood is suddenly and for- 
cibly thrown into the aorta by the hypertrophied and dilated left 
ventricle, thus causing the characteristically sharp and sudden rise 
in the peripheral arteries. The arteries then empty themselves in 
two directions at once, forward into the capillaries and backward 
into the heart through the incompetent aortic valves; hence the 
sudden collapse in the pulse which, together with its sharp and 
sudden rise, are its important characteristics. The arteries are 
large and often elongated so as to be thrown into curves. 

' Not infrequently one can demonstrate that the radial pulse is 
delayed or follows the apex impulse after a longer interval than 
in normal persons. While compensation lasts, the pulse is usually 
regular in force and rhythm. Irregularity is therefore an especially 
grave sign, much more so than in any other valvular lesion. 

Percussion. 

Percussion adds but little to the information obtained by inspec- 
tion and palpation, but verities the results of these methods of in- 
vestigation respecting the increased size of the heart, and especially 
of the left ventricle, which may reach enormous dimensions, espe- 
cially in cases occurring in young persons. The heart may be 
increased to more than four times its normal weight. 

Auscultation. 

In rare cases there may be absolutely no murmur and the diag- 
nosis may be impossible during life, though it may be suspected 
by reason of the above-mentioned signs in the peripheral arteries. 
But although the murmur is seldom entirely absent, it is often so 
faint as to be easily overlooked. This is especially true in cases 
occurring in elderly people, and when the patient has been for a 
considerable time at rest. The difficulty of recognizing certain 
cases of aortic regurgitation during life is shown by the fact that 
out of sixty-five cases of aortic regurgitation demonstrated at au- 
topsy in the Massachusetts General Hospital, only forty-four were 
recognized during life. 



VALVULAR LESIONS. 



235 



In the majority of cases, however, the characteristic diastolic 
murmur is easily heard if one listens in the right place, and when 
heard it is the most distinctive and trustworthy of all cardiac mur- 
murs. It almost invariably points to aortic regurgitation and to 
nothing else. 

The murmur of aortic regurgitation, as has been already men- 
tioned, is diastolic in time. 1 Its maximum intensity is usually not 




Fig. 13? 



-Position of the Point of Maximum Intensity of the Murmur of Aortic Regurgitation. 
The dots are most thickly congregated where the murmur is oftenest heard. 



in the conventional aortic area {second right interspace) , but on the 
left side of the sternum about the level of the fourth left costal carti- 
lage. In about one-tenth of the cases, and especially when the 
aortic arch is much dilated, the murmur is best heard in the con- 
ventional aortic area. Occasionally there are two points at which 
it may be loudly heard — one in the second right interspace and the 
other at or near the apex of the heart, while between these points 

1 Another murmur, systolic in time, which almost always accompanies 
the diastolic murmur, is usually due to roughening of the edges of the aortic 
valves or to dilatation of the aortic arch. This murmur must not be assumed 
to mean aortic stenosis (see. below, £• 243). 



236 PHYSICAL DIAGNOSIS. 

the murmur is faint. This is probably due to the fact that the 
left ventricle, through which the murmur is conducted, approaches 
the surface of the chest only at the apex, while the intermediate space 
is occupied by the right ventricle, which often fails readily to trans- 
mit murmurs produced at the aortic orifice. Less frequently the 
murmur of aortic regurgitation is heard with maximum intensity 
at the second or third left costal cartilage or in the region of the 
ensiform cartilage (see Fig. 137). 

From its seat of maximum intensity (i.e., usually from the 
fourth left costal cartilage) the murmur is transmitted in all direc- 
tions, but not often beyond the precordia. In about one-third of 
the cases it is transmitted to the left axilla or even to the back. 
It is sometimes to be heard in the subclavian artery and the 
great vessels of the neck; in other cases two heart sounds are 



ls * 1st 

2nd 



2nd 



Fig. 138. -Short Diastolic Murmur Not Replacing the Second Sound. 

audible in the carotid, but no murmur. The murmur is usually 
blowing and relatively high pitched, sometimes musical. Its inten- 
sity varies much, but is most marked at the beginning of the mur- 
mur, giving the impression of an accent there. It may occupy the 
whole of diastole or only a small portion of it — usually the earlier 
portion (see Fig. 138). Late diastolic murmurs are rare. The mur- 
mur may or may not replace the second sound of the heart. Broad- 
bent believes that when it does not obliterate the second sound, 
the lesion is usually less severe than when only the murmur is to 
be heard. Allbutt dissents from this opinion. 

In listening for the aortic second sound with a view to gauging 
the severity of the lesion, it is best to apply the stethoscope over the 
right carotid artery, as here we are less apt to be confused by the 
murmur or by the pulmonic second sound. 

The position of the patient's body has but little effect upon the 
murmur — less than upon murmurs produced at the mitral orifice. 



valvular lesions. 237 

The first sound at the apex is generally loud and long. There 
is no accentuation of the pulmonic second. 

Over the larger peripheral arteries, especially over the femoral 
artery, one hears in most cases a sharp, short systolic sound ("pis- 
tol-shot sound ") due to the sudden filling of the unusually empty 
artery ; this sound is merely an exaggeration of what may be heard 
in health. Pressure with the stethoscope will usually bring out a 
systolic murmur (as also in health), and occasionally a diastolic 
murmur as well (Duroziez's sign). This diastolic murmur in the 
peripheral arteries, obtained on pressure with the stethoscope, is 
practically never heard except in aortic regurgitation. It is thought 
by some to be due to the regurgitant current in the great vessels 
which in very marked cases may extend as far as the femoral ar- 
tery. Duroziez's sign is a comparatively rare one, not present in 
most cases of aortic regurgitation, and usually disappears when 
compensation fails. 

Summary and Differential Diagnosis. 

A diastolic murmur heard with the maximum intensity about 
the fourth left costal cartilage (less often in the second right inter- 
space or at the apex) gives us almost complete assurance of the 
existence of aortic regurgitation. From pulmonary regurgitation, 
an exceedingly rare lesion, the disease is distinguished by the pres- 
ence of predominating hypertrophy of the left ventricle with a 
heaving apex impulse and by the following arterial phenomena : 

(a) Visible pulsation in the peripheral arteries. 

(b) Capillary pulsation. 

(c) "Corrigan " pulse. 

(d) " Pistol-shot sound " in the femoral artery. 

(e) Duroziez's sign. 

Cardiopulmonary murmurs (see page 197) are occasionally dias- 
tolic, but are very markedly influenced by position and by respira- 
tion, while aortic murmurs are but slightly modified. 

The very rare functional diastolic murmur, transmitted from the 
veins of the neck and heard over the base of the heart in cases of 
grave anaemia, may be obliterated by pressure over the bulbus jugu- 
laris. Such pressure has no effect upon the murmur of aortic regur- 



238 PHYSICAL DIAGNOSIS. 

gitation. I have recently reported {Johns Hopkins Bull., May, 
1903) three cases of intense anaemia associated with diastolic mur- 
murs exactly like those of aortic regurgitation, but proved post 
mortem to be independent of any valvular lesion The arterial 
phenomena were not marked, but the diagnosis of such cases is 
very hard. Luckily they are rare. The origin is obscure. 

It must be remembered that aortic regurgitant murmurs are 
often exceedingly faint, and should be listened for with the greatest 
care and under the most favorable conditions. 

Estimation of the Extent and Gravity of the Lesion, 

The extent of the lesion is roughly proportional to — 

(a) The amount of hypertrophy of the left ventricle. 

(b) The degree to which the pulse collapses during diastole 
(provided the radial is not so much calcified as to make collapse 
impossible). 

(c) The degree to which the murmur replaces the second sound 
as heard over the right carotid artery (Broadbent). 

Irregularity of the pulse is a far more serious sign in this dis- 
ease than in lesions of the mitral valve, and indicates the beginning 
of a serious failure of compensation. 

Another grave sign is a diminution in the intensity of the 
murmur. 

Complications. 

(1) Dilatation of the Aorta. — Diffuse dilatation of the aortic arch 
is usually associated with aortic regurgitation and may produce a 
characteristic area of dulness to the right of the sternum (see Fig. 
134). Not infrequently this dilatation is the cause of a systolic 
murmur to be heard over the region of the aortic arch and in the 
great vessels of the neck. 

(2) Roughening of the Aortic Valves. — In almost ail cases of aortic 
regurgitation the valves are sufficiently roughened to produce a 
systolic murmur as the blood flows over them. This murmur is 
heard at or near the conventional aortic area, and may be trans- 
mitted into the carotids. (The relation of these murmurs to the 
diagnosis of aortic stenosis will be considered with the latter lesion.) 



VALVULAR LESIONS. 239 

(3) The return of arterial blood through the aortic valves into 
the left ventricle produces in time both hypertrophy and dilatation 
of this chamber, and results ultimately in a stretching of the mitral 
orifice which renders the mitral curtains incompetent. The result 
is a " relative mitral insufficiency " i.e., one in which the mitral valve 
is intact but too short to reach across the orifice which it is in- 
tended to close. Such an insufficiency of the mitral occurs in most 
well-marked cases ; it temporarily relieves the overdistention of the 
left ventricle and often the accompanying angina, although at the 
cost of engorging the lungs. 1 

(4) The Austin Flint Murmur. — The majority of cases of aortic 
regurgitation are accompanied by a presystolic murmur at the apex,, 
which may be due to a genuine mitral stenosis or may be produced 
in the manner suggested by Austin Flint. (For a fuller discussion 
of this murmur see above, p. 227.) 

(5) Aortic stenosis frequently supervenes in cases of aortic re- 
gurgitation, and results in a more or less temporary improvement in 
the patient's condition. It has the effect of increasing the intensity 
of the diastolic murmur, since the regurgitating stream has to pass 
through a smaller opening. 

The general visible arterial pulsation becomes much less marked 
if stenosis supervenes on regurgitation. 



AOETIC STENOSIS. 

Uncomplicated aortic stenosis is by far the rarest of the valvu- 
lar lesions of the left side of the heart, as well as the most difficult 
to recognize. Out of two hundred and fifty- two autopsies made at 
the Massachusetts General Hospital in cases of valvular disease 
there was not one of unconrplicated aortic stenosis. Twenty -nine 
cases occurred in combination with aortic regurgitation. During 
life the diagnosis of aortic stenosis is frequently made, but often on 
insufficient evidence — i.e., upon the evidence of a systolic murmur 
heard with maximum intensity in the second right intercostal space 

1 This relative insufficiency of the mitral valve has been termed its "safety- 
valve" action, but the safety is but temporary and dearly bought. 



240 PHYSICAL DIAGNOSIS. 

and transmitted into the vessels of the neck. Such a murmur does 
indeed occur in aortic stenosis, but is by no means peculiar to this 
condition. Of the other diseases which produce a similar murmur 
more will be said under Differential Diagnosis. 

For the diagnosis of aortic stenosis we need the following evi- 
dence : 

(1) A systolic murmur heard best in the second right intercostal 
space and transmitted to the neck. 

(2) The characteristic pulse (vide infra). 

(3) A palpable thrill (usually). 

(4) Absence or great enfeeblement of the aortic second sound. 
Of these signs the characteristic pulse is probably the most im- 







Fig. 139.— Aortic Stenosis. The heart is in systole and the blood column is obstructed by the 
narrowed aortic ring. The mitral is closed (as it should be). 

portant, and no diagnosis of aortic stenosis is possible without it. 
The heart may or may not be enlarged. 

Each of these points will now be described more in detail. 

(1) The Murmur. 

(a) The maximum intensity of the murmur, as has already been 
said, is usually in the second right intercostal space near the ster- 
num or a little above that point near the sterno-clavicular articula' 
tion, but it is by no means uncommon to find it lower down, i.e., 



VALVULAR LESIONS. 



241 



in the third, fourth, or fifth right interspace, and occasionally it is 
best heard to the left of the sternum in the second or third inter- 
costal space, (b) The time of the murmur is late systolic ; that is, 
it follows the apex impulse at an appreciable interval, contrasting 
in this respect with the systolic murmur usually to be heard in 
mitral regurgitation, (c) The murmur is usually widely transmit- 
ted, often being audible over the whole chest and occasionally over 
the skull and the arterial trunks of the extremities (see Fig. 140). 
It is usually heard less well over that portion of the precordia oc= 
cupied by the right ventricle, while, on the other hand, it is rela- 
tively loud in the region of the apex impulse, whither it is trans- 
mitted through the left ventricle. The same line of transmission 



Maximum intensity 
of systolic mur- 
mur and thrill. 




Fig. 140.— Aortic Stenosis. 



The murmur is audible over the shaded area and sometimes over 
the whole chest. 



was mentioned above as characteristic of the murmur of aortic re- 
gurgitation in many cases. The murmur is also to be heard over 
the carotids and subclavians, and can often be traced over the tho- 
racic aorta along the spine and down the arms. 

Until compensation fails the murmur is apt to be a very loud 
one, especially in the recumbent position; it is occasionally au- 
dible at some distance from the chest, and is often rough and 
vibrating, sometimes musical or croaking. Its length is unusually 
16 



242 PHYSICAL DIAGNOSIS. 

great, extending throughout the whole of systole, but to this rule 
there are occasional exceptions. The first sound in the aortic re- 
gion is altogether obliterated, as a rule, and the second sound is 
either absent or very feeble. 1 

(2) The Pulse. 

Owing to the opposition encountered by the left ventricle in 
its attempt to force blood into the aorta, its contraction is apt to 
be prolonged ; hence the pulse wave rises gradually and late, and falls 
aiuay sloivly. This is shown very well in sphygmographic tracings 
(see Fig. 141). But further, the blood thrown into the aorta by the 
left ventricle is prevented, by the narrowing of the aortic valves, 
from striking upon and expanding the arteries with its ordinary 
force ; hence the pulse wave is not only slow to rise but small in 




Fig. 141.— Sphygmographic Tracing of the Pulse in Uncomplicated Aortic Stenosis. Compare 
with the normal pulse wave and with that of aortic regurgitation (page 174). 

height, contrasting strongly with the powerful apex beat ("pulsus 
parvus"). Again, the delay in the emptying of the left ventricle, 
brought about by the obstruction at the aortic valves, renders the 
contractions of the heart relatively infrequent, and hence the pulse 
is infrequent (pulsus varus) as well as small and slow to rise. The 
"pulsus varus, parvus, tardus " is, therefore, a most constant and 
important point in diagnosis, but unfortunately it is to be felt 
in perfection only in the very rare cases in which aortic stenosis 
occurs uncomplicated. When stenosis is combined with regurgita- 
tion, as is almost always the case, the above-described qualities of 
the pulse are greatly modified as a result of the regurgitation. It 

1 "Occasionally, as noted by W. H. Dickinson, there is a musical murmur 
of great intensity in the region of the apex, probably due to a slight regurgita- 
tion at high pressure through the mitral valve."— Osler. 



VALVULAR LESIONS. 243 

is also to be remembered that the pulse of aortic stenosis is by no 
means unalterable and does not exhibit its typical plateau at all 
times. 

A less characteristic, but decidedly frequent, variation in the 
pulse wave of aortic stenosis is the anacrotic curve. The slow, 
long pulse with a long plateau at the summit is seen also in some 
cases of mitral stenosis and renal disease, and is not peculiar to 
aortic stenosis, but taken in connection with the other signs of the 
disease it has great value in diagnosis. 

(3) The Thrill. 

In the majority of cases an intense purring vibration may be 
felt if the hand is laid over the upper portion of the sternum, espe- 
cially over the second right intercostal space. This thrill is con- 
tinued into the carotids, can occasionally be felt at the apex, and 
rarely over a considerable area of the chest. It is a very important 
aid in the diagnosis of aortic stenosis, but is by no means pathog- 
nomonic, since aneurism may produce a precisely similar vibration 
of the chest wall. 

The heart is slightly enlarged to the left and downward as a 
rule, but the apex impulse is unusually indistinct, " a well-defined 
and deliberate push of no great violence" (Broadbent). Corre- 
sponding to the protracted sustained systole the first sound at the 
apex is dull and long, but not very loud. 

Differential Diagnosis. 

A systolic murmur heard loudest in the second right intercostal 
space is by no means peculiar to aortic stenosis, but may be due to 
any of the following conditions : 

(a) Eoughening, stiffness, fenestration, or slight congenital mal- 
formation of the aortic valves. 

(b) Eoughening or diffuse dilatation of the arch of the aorta. 

(c) Aneurism of the aorta or innominate artery. 

(d) Functional murmurs. 

(e) Pulmonary stenosis. 
(/) Open ductus arteriosus. 
(g) Mitral regurgitation. 






244 PHYSICAL DIAGNOSIS. 

(a and b) The great majority of such systolic murmurs at the 
base of the heart, first appearing after middle life, are due to the 
causes mentioned above under a, b, and c. In such cases it is usu- 
ally combined with accentuation and ringing quality of the aortic 
second sound owing to the arterio -sclerosis and high arterial tension 
associated with the changes which produce the murmur, This 
accentuation of the aortic second sound enables us, except in extraor- 
dinarily rare cases, to exclude aortic stenosis, in which the intensity 
of the aortic second sound is almost always much reduced. 

Diffuse dilatation of the aorta, such as often accompanies aortic 
regurgitation, is a frequent cause of a systolic murmur loudest in 
the second right interspace. This may be recognized in certain 
cases by the characteristic area of dulness on percussion and by its 
association with aortic regurgitation of long standing (see Fig. 134). 

Eoughening of the intima of the aorta (endaortitis) is always to 
be suspected in elderly patients with calcified and tortuous periph- 
eral arteries, and such a condition of the aorta doubtless favors the 
occurrence of a murmur, especially when accompanied by a slight 
degree of dilatation. The absence of a thrill and a long, slow 
pulse with a low maximum serves to distinguish such murmurs 
from those of aortic stenosis. 

(c) Aneurism of the ascending arch of the aorta or of the in- 
nominate artery may give rise to every sign of aortic stenosis except 
the characteristic pulse and the diminution of the aortic second 
sound. In aneurism we may have a well-marked tactile thrill and 
a loud systolic murmur transmitted into the neck, but there is 
usually some pulsation to be felt in the second right intercostal 
space and often some difference in the pulses or in the pupils, as 
well as a history of pain and symptoms of pressure upon the tra- 
chea and bronchi or recurrent laryngeal nerve. In aneurism the 
aortic second sound is usually loud and accompanied by a shock, 
and the pulse shows none of the characteristics of aortic stenosis. 

(d) Functional murmurs, sometimes known as "haeinic," are 
occasionally best heard in the aortic area instead of in their usual 
situation (second left intercostal space). They occur especially in 
young, anaemic persons, are not accompanied by any cardiac en- 



VALVULAR LESIONS. 245 

largement, by any palpable thrill, any diminution in the aortic 
second sound, or any distinctive abnormalities in the pulse. 

(e) Pulmonary stenosis, a rare lesion, is manifested by a sys- 
tolic murmur and by a thrill whose maximum intensity is usually 
on the left side of the sternum. In the rare cases in which this 
murmur is best heard in the aortic area it may be distinguished 
from the murmur of aortic stenosis by the fact that it is not trans- 
mitted into the vessels of the neck, has no effect upon the aortic 
second sound, and is not accompanied by the characteristic changes 
in the pulse. 

(/) The murmur due to persistence of the ductus arteriosus 
may last through systole and into diastole ; it may be accompanied 
by a thrill, but does not affect the aortic second sound nor the 
pulse. 

{g) The systolic murmur of aortic stenosis may be heard loudly at 
the apex, and hence the lesion may be mistaken for mitral regur- 
gitation. But the maximum intensity of the murmur of aortic 
stenosis is almost invariably in the aortic area, and its association 
with a thrill and a long, slow pulse should enable us easily to dif- 
ferentiate the two lesions. 

By the foregoing differentiae aortic stenosis may be distinguished 
from the other conditions which resemble it, provided it occurs 
uncomplicated, but unfortunately this is very rare. As a rule, it 
occurs in connection with aortic regurgitation, and its characteristic 
signs are therefore obscured or greatly modified by the signs of the 
latter disease. We may suspect it in such cases (provided the mi- 
tral valve is sufficient) when we have, in addition to the signs of 
aortic regurgitation, a systolic murmur and palpable thrill in the 
aortic area transmitted into the great vessels, a modification of the 
Corrigan pulse in the direction of the "pulsus tardus, rarus, par- 
vus" and less visible arterial pulsation than is to be expected in 
pure aortic regurgitation. 

Occasionally one can watch the development of an aortic steno- 
sis out of Avhat was formerly a pure regurgitant lesion, the stenosis 
gradually modifying the characteristics of the previous condition. 
One must be careful, however, to exclude a relative mitral msuffi- 






246 PHYSICAL DIAGXOSIS. 

ciency which, as lias been already mentioned above, is very apt to 
supervene in cases of aortic disease, owing to dilatation of the mi- 
tral orifice, and which may modify the characteristic signs of aortic 
regurgitation very much as aortic stenosis does. 

TRICUSPID REGURGITATION. 

Endocarditis affecting the tricuspid valve is rare in post-foetal 
life ; in the foetus it is not so uncommon. In cases of ulcerative 
or malignant endocarditis occuring in adult life, the tricuspid valve 
is occasionally involved, but the majority of cases of tricuspid dis- 
ease occur as a result of disease of the mitral valve and in the follow- 
ing manner : Hypertrophy of the right ventricle occurs as a result 
of the mitral disease, is followed in time by dilatation, and with 
this dilatation comes a stretching of the ring of insertion of the 
tricuspid valve, and hence a regurgitation through that valve. Tri- 
cuspid regurgitation, then, occurs in the latest stages of almost 
every case of mitral disease and sometimes during the severer at- 
tacks of failing compensation. 

Out of 405 autopsies at Guy's Hospital in which evidence of 
tricuspid regurgitation was found, 271, or two-thirds, resulted from 
mitral disease, 68 from myocardial degeneration, 55 from pulmonary 
disease (bronchitis, emphysema, cirrhosis of the lung). Very few of 
these cases had been diagnosed during life, and in all of them the 
valve was itself healthy but insufficient to close the dilated orifice. 

Gibson and some other writers believe that temporary tricuspid 
regurgitation is the commonest of all valve lesions, and results from 
weakening of the right ventricle in connection with states of anae- 
mia, gastric atony, fever, and many other conditions. It is very 
difficult to prove or disprove such an assertion. 

Tricuspid regurgitation is often referred to as serving like the 
opening of a "safety value" to relieve a temporary pulmonary en- 
gorgement. This " safety-valve " action, however, may be most 
disastrous in its consequences to the organism as a whole, despite 
the temporary relief which it affords to the overfilled lungs. The 
engorgement is simply transferred to the liver and thence to the 



VALVULAR LESIONS. 247 

abdominal organs and the lower extremities, so that as a rule the 
advent of tricuspid regurgitation is recognized not as a relief but 
as a serious and probably fatal disaster. 

Physical Signs. 

(1) A systolic murmur is heard loudest at or near the fifth left 
costal cartilage. 

(2) Systolic venous pulsation in the jugulars and in the liver. 

(3) Engorgement of the right auricle producing an area of dul- 
ness beyond the right sternal margin. 

(4) Intense cyanosis. 

(1) The Murmur. — The maximum intensity of the systolic mur- 
mur of tricuspid regurgitation is usually near the junction of the fifth 
or sixth left costal cartilages with the sternum. Leube finds the 
murmur a rib higher up, but it is generally agreed that the tricuspid 
area is a large one, so that the murmur may be heard anywhere 
over the lower part of the sternum or even to the right of it. On the 
other hand, there are some tricuspid murmurs which are best heard 
at a point midway between the apex impulse and the ensif orm carti- 
lage. The murmur is not widely transmitted and is usually inaudi- 
ble in the back; at the end of expiration its intensity is increased- 

In some cases we have no evidence of tricuspid regurgitation 
other than the murmur just described, but — 

(2) Of more importance in diagnosis is the presence of a sys- 
tolic pulsation in the external jugular veins and of the liver, which 
unfortunately is not always present, but which when present is 
pathognomonic. I have already explained (see p. 88) the distinc- 
tion between true systolic jugular pulsation, which is practically 
pathognomonic of tricuspid regurgitation, and simple presystolic 
undulation or distention of the same veins, which has no necessary 
relation to this disease. The decisive test is the effort permanently 
to empty the vein by stroking it upward from below. If it in- 
stantly refills from below and continues to pulsate, tricuspid regur- 
gitation is almost certainly present. If, on the other hand, it does 
not refill from below, the cause must be sought elsewhere. 



248 



PHYSICAL DIAGNOSIS. 



Pulsation in the liver must be distinguished from the "jogging " 
motion which may be transmitted to it from the abdominal aorta or 
from the right ventricle. To eliminate these transmitted impulses 
one must be able to grasp the liver binianually, one hand in front 
and one resting on the lower ribs behind, and to feel it distinctly ex- 
pand with every systole, or else to take its edge in the hand and 
to feel it enlarge in one's grasp with every beat of the heart. 



Dilated right 
auricle. 



Systolic munnur. . — — 




Enlarged and pul« 
sating liver. 



Fig. 142.— Tricuspid Regurgitation. The murmur is heard best over the shaded area. 



Pressure upon the liver often causes increased distention and pulsa- 
tion of the external jugulars if tricuspid regurgitation is present. 

(3) Enlargement of the heart, both to the right and to the left, 
as well as downward, can usually be demonstrated. In rare cases 
a dilatation of the right auricle may be suggested by a percussion 
outline such as that shown in Fig. 142. 

The pulmonic second sound is usually not accented. The im- 
portance of this in differential diagnosis will be mentioned pres- 
ently. If a progressive diminution in the intensity of the sound 
occurs under observation, the prognosis is very grave. 

(4) Cyanosis is usually very great, and dyspnoea and pulmonary 
oedema often make the patient's condition a desperate one. 



VALVULAR LESIONS. 249 

Differential Diagnosis. 

The statistics of the cases autopsied at the Massachusetts Gen- 
eral Hospital show that tricuspid regurgitation is less often recog- 
nized during life than any other valvular lesion. The diagnosis 
was made ante mortem on only five out of twenty-nine cases. 
This is due to the following facts : 

(a) Tricuspid regurgitation may be present and yet give rise to 
no physical signs which can be recognized during life. 

(b) Tricuspid regurgitation occurs most frequently in connec- 
tion with mitral regurgitation; hence its signs are frequently 
masked by those of the latter lesion. It is, therefore, a matter of 
great importance as well as of great difficulty to distinguish tricus- 
pid regurgitation from 

(1) Mitral Regurgitation. 

The difficulties are obvious. The murmur of mitral regurgita- 
tion has its maximum intensity not more than an inch or two from 
the point at which the tricuspid murmur is best heard. Both are 
systolic in time. They are, therefore, to be distinguished only — 

(a) In case we can demonstrate that there are two areas in 
which a systolic murmur is heard with relatively great intensity, 
with an intervening space over which the murmur is less clearly to 
be heard (see Fig. 143). 

(b) Occasionally the two systolic murmurs are of different pitch 
or of different quality, and may be thus distinguished. 

(c) Tricuspid murmurs are not transmitted into the left axilla 
and are rarely audible in the back, and this fact is of value in case we 
have to distinguish between uncomplicated tricuspid regurgitation 
and uncomplicated mitral regurgitation. Unfortunately these le- 
sions are very apt to occur simultaneously, so that in practice our 
efforts are generally directed toward distinguishing between a pure 
mitral regurgitation and one complicated by tricuspid regurgitation. 

(d) In cases of doubt the phenomena of venous pulsation in the 
jugulars and in the liver are decisive if present, but their absence 
proves nothing. 



250 



PHYSICAL DIAGNOSIS. 



(e) Accentuation of the pulmonic second sound is almost inva- 
riably present in uncomplicated mitral disease and is apt to disap- 
pear in case the tricuspid begins to leak, since engorgement of the 
lungs is thereby for the time relieved, but in many cases the pul- 
monic second sound remains most unaccountably strong even when 
the tricuspid is obviously leaking. 

(2) From " functional " systolic murmurs tricuspid insufficiency 
may generally be distinguished by the fact that its murmur is best 




Fig. 143.— Two Systolic Murmurs (Mitral and Tricuspid with a " Vanishing Point " between. 



heard in the neighborhood of the ensiform cartilage, and not in the 
second right intercostal space where most functional murmurs have 
their seat of maximum intensity. Functional murmurs are unac- 
companied by venous pulsation, cardiac dilatation, or cyanosis. 

(3) Occasionally a pericardial friction rub simulates the mur- 
mur of tricuspid insufficiency, but, as a rule, pericardial friction is 
much more irregular in the time of its occurrence and is not regu- 
larly synchronous with any definite portion of the cardiac cycle. 

Tricuspid Stexosis. 

One of the rarest of valve lesions is narrowing of the tricuspid 
valve. No case has come under my observation, and in 1898, Her- 



VALVULAR LESIONS. 251 

rick was able to collect but 154 cases from the world's literature. 
Out of these 154 cases, 138, or 90 per cent, were combined with 
mitral stenosis, and only 12 times has tricuspid stenosis been known 
to occur alone. 1 These observations account for the fact that tri- 
cuspid stenosis has hardly ever been recognized during life, since the 
murmur to which it gives rise is identical in tune and quality and 
nearly identical in position with that of mitral stenosis. Narrow- 
ing of the tricuspid valve is to be diagnosed, therefore, only by the 
recognition of a presystolic murmur best heard in the tricuspid area 
and distinguished either by its pitch, quality, or position from the 
other presystolic murmur due to the mitral stenosis which is almost 
certain to accompany it. 

The heart is usually enlarged, especially in its transverse direc- 
tion, but the enlargement is just such as mitral stenosis produces, 
and does not aid our diagnosis at all. 

The diagnosis is still further complicated in many cases by the 
presence of an aortic stenosis in addition to a similar lesion at the 
tricuspid and mitral valves, so that it seems likely that in the future 
as in the past the lesion will be discovered first at autopsy. 

Pulmonary Regurgitation. 

Organic disease of the pulmonary valve is excessively rare in 
post-foetal life, but may occur as part of an acute ulcerative or 
septic endocarditis. A temporary functional regurgitation through 
the pulmonary valve may be brought about by any cause producing 
very high pressure in the pulmonary artery. I have known two 
medical students with perfectly healthy hearts who were able, by 
prolonged holding of the breath, to produce a short, high-pitched 
diastolic murmur best heard in the second and third left intercostal 
spaces and ceasing as soon as the breath was let out. Of the occur- 
rence of a murmur similarly produced under pathological condi- 
tions, especially in mitral stenosis, much has been written by 
Graham Steell. 

1 Out of 87 cases collected from the post-mortem records of Guy's Hos- 
pital, 85, or 97 per cent, were associated with still more extensive mitral 
Stenosis, 



252 PHYSICAL DIAGNOSIS. 

Froru the diastolic murmur of aortic regurgitation we may dis- 
tinguish the diastolic murmur of pulmonary incompetency by the 
fact that the latter is best heard over the pulmonary valve, is never 
transmitted to the apex of the heart nor to the great vessels, and 
is never associated Avith a Corrigan pulse nor with capillary pulsa- 
tion. 1 The right ventricle is hypertrophic d, the pulmonic second 
sound is sharply accented and followed immediately by the murmur. 
Evidences of septic embolism of the lungs are frequently present 
and assist us in diagnosis. The regurgitation which may take 
place through the rigid cone of congenital pulmonary stenosis is 
not recognizable during life. 

Pulmonary Stenosis. 

Among the rare congenital lesions of the heart valves this is 
probably the commonest. The heart, and particularly the right 
ventricle, is usually much enlarged. There is a history of cyanosis 
and dyspnoea since birth. Pulmonary tuberculosis complicates from 
one-fourth to one-third of all cases. A systolic thrill is usually to 
be felt in the second left intercostal space, and a loud systolic mur- 
mur is heard in the same area. The pulmonic second sound is weak. 

The region in which this murmur is best heard has been happily 
termed the "region of romance'''' on account of the multiplicity of 
mysterious murmurs which have been heard there. The systolic 
murmur of pulmonary stenosis must be distinguished from 

(a) Functional murmurs due to anaemia and debility or to severe 
muscular exertion, and possibly associated with a dilatation of the 
conus arteriosus. 

(b) Uncovering of the conus arteriosus through lack of expan- 
sion of the lung. 

(c) Aortic stenosis. 

(d) Mitral regurgitation. 

(e) Aneurism. 

(/) Roughening of the intima of the aortic arch. 

1 By registering the variations of pressure in the tracheal column of air 
Gerhardt has shown graphically that a systolic pulsation of the pulmonary cap- 
illaries may occur in pulmonary regurgitation. With the stethoscope a sys- 
tolic whiff may be heard all over the lungs. 



VALVULAR LESIONS. 253 

(a and b) Functional murmurs, and those produced in the conus 
arteriosus, are rarely if ever accompanied by a thrill, are rarely so 
loud as the murmur of pulmonary stenosis, and are not associated 
with dyspnoea, cyanosis, and enlargement of the right ventricle. 

(c) The murmur of aortic stenosis is usually upon the right side 
of the sternum and is transmitted to the neck, whereas the murmur 
of pulmonary stenosis is never so transmitted and is not associated 
with characteristic changes in the pulse (see above, p. 242). 

(d) The murmur of mitral regurgitation is occasionally loudest 
in the region of the pulmonary valve, but differs from the murmur 
of pulmonary stenosis in being, as a rule, transmitted to the back 
and axilla and associated with an accentuation of the' pulmonary 
second sound. 

(e) Aneurism may present a systolic murmur and thrill similar 
to those found in pulmonary stenosis, but may usually be distin- 
guished from the latter by the presence of the positive signs of aneur- 
ism, viz. — pulsation, and dulness in the region of the murmur, and 
signs of pressure on the trachea or on other structures in the medi- 
astinum. 

(/) Eoughening of the aortic arch occurs after middle life, 
while pulmonary stenosis is usually congenital. The murmur due 
to roughening may be transmitted into the carotids ; that of pul- 
monary stenosis never. Enlargement of the right ventricle is char- 
acteristic of pulmonary stenosis, but not of aortic roughening. 

COMBINED VALVULAR LESIONS. 

It is essential that the student should understand from the first 
that the number of murmurs audible in the precordia is no gauge 
for the number of valve lesions. We may have four distinct mur- 
murs, yet every valve sound except one. This is often the case in 
aortic regurgitation — systolic and diastolic murmurs at the base of 
the heart, systolic and presystolic at the apex, yet no valve in- 
jured except the aortic. In such a case the systolic aortic murmur 
is due to roughening of the aortic valve. The systolic apex mur- 
mur results from relative mitral leakage (with a sound valve). The 
presystolic apex murmur is of the "Flint" type. Hence in this 



254 PHYSICAL DIAGNOSIS. 

case the diastolic murnmr alone of the four audible murmurs is due 
to a valvular lesion. 

It is a good rule not to multiply causes unnecessarily, and to 
explain as many signs as possible under a single hypothesis In 
the above example the mitral leak might be due to an old endocar- 
ditis, and there might be mitral stenosis and aortic stenosis as well, 
but since we can explain all the signs as results — direct and indirect 
— of one lesion (aortic regurgitation) it is better to do so, and post- 
mortem experience shows that our diagnosis is more likely to be 
right when it is made according to this principle. 

The most frequent combinations are : 

(1) Mitral regurgitation with mitral stenosis. 

(2) Aortic regurgitation with mitral regurgitation (with or with- 
out stenosis). 

(3) Aortic regurgitation with aortic stenosis, with or without 
mitral disease. 

(1) Double Mitral Disease. 

(a) It very frequently happens that the mitral valve is found 
to be both narrowed and incompetent at autopsy when only one of 
these lesions had been diagnosed during life. In fact mitral steno- 

lst 



2nd 

_L 



J 



Fig. 144.— Mitral Stenosis and Regurgitation, showing relation of murmur to first heart sound. 

sis is abnost never found at autopsy with rut an associated regurgi- 
tation, so that it is fairly safe to assume, whenever one makes the 
diagnosis of mitral stenosis, that mitral regurgitation is present as 
well, whether it is possible to hear any regurgitant murmur or not 
(see Fig. 144). 

(b) On the other hand, with a double mitral lesion one may 
have only the regurgitant murmur at the mitral valve and nothing 
to suggest stenosis unless it be a surprising sharpness of the first 
mitral sound. In chronic cases the changeableness of the murmurs 
both in type and position is extraordinary. One often finds at one 



VALVULAR LESIONS. 



255 



visit evidences of mitral stenosis and at another evidences of mitral 
regurgitation alone. Either murmur may disappear altogether for 
a time and reappear subsequently. This is peculiarly true of the pre- 
systolic murmur, which is notoriously one of the most fleeting and 
uncertain of all physical signs. 

As a rule the same inflammatory changes which produce mitral 
regurgitation in early life result as they extend in narrowing the 
mitral valve, so that the signs of stenosis come to predominate in 
later years. Coincidently with this narrowing of the diseased valve 
a certain amount of improvement in the patient's symptoms may 
take place, and Eosenbach regards the advent of stenosis in such a 
case as an attempt at a regenerative or compensatory change. In 
many cases, however, no such amelioration of the symptoms follows. 

(2) Aortic Regurgitation with Mitral Disease. 

The signs of mitral disease occurring in combination with 
aortic regurgitation do not differ essentially from those of pure 



Systolic murmur 
over dilated- 
aortic arch. 




Maximum intensity 
and diastolic mur- 
mur, conducted 
up and down. 



Systolic murmur. 



Fig. 145.— Aortic and Mitral Regurgitation. The shaded areas are those in which the murmurs 

are loudest. 



mitral disease except that the enlargement of the heart is apt to 
be more general and correspond less exclusively to the right ven- 
tricle (see Figs. 145 and 146). The manifestations of the aortic le- 



256 PHYSICAL DIAGNOSIS. 

sion, on the other hand, are considerably modified by their associa- 
tion with the mitral disease. The Corrigan pulse is distinctly less 
sharp at the summit and rises and falls less abruptly. Capillary 

l>t 1st 

I III 2nd III 1 1 2nd 
lillllllll llllllllilliiiiiii IllllKlllinii. llllllHiiiiiiiin 

Fig. 146.— Showing Relation of Murmurs to Heart Sound in Regurgitation at the Aortic and 

Mitral Valves. 

pulse is less likely to be present, and the throbbing of the peripheral 
arteries is less often visible. 

(3) Aortic Regurgitation with Aortic Stenosis. 

If the aortic valves are narrowed as well as incompetent, we 
find very much the same modification of the physical signs charac- 
teristic of aortic regurgitation as is produced by the advent of a 
mitral lesion ; that is to say, the throbbing in the peripheral ar- 
teries is less violent, the characteristics of the radial pulse are less 
marked, and the capillary pulsation is not always to be obtained 
at all. Indeed, this blunting of all the typical manifestations of 
aortic regurgitation may give us material aid in the diagnosis of 
aortic stenosis, provided always that the mitral valve is still per- 
forming its function. 

(4) The association of mitral disease with tricuspid insufficiency 
has been already described on p. 218. 



CHAPTER XI. 

PAKIETAL DISEASE.— CAEDIAC NEUROSES.— CONGENI- 
TAL MALFORMATIONS OF THE HEART. 

Parietal Disease of the Heart. 

Acute Myocarditis. 

The myocardium is seriously, though not incurably, affected in 
all continued fevers, owing less to the fever itself than to the tox- 
aemia associated with it. "Cloudy swelling," or granular degener- 
ation of the muscle fibres, is produced by relatively mild infections, 
while a general septicaemia due to pyogenic organisms may produce 
extensive fatty degeneration of the heart within a few days. 

The physical signs are those of cardiac weakness. The most 
significant change is in the quality of the first sound at the apex 
of the heart, which becomes gradually shorter until its quality is 
like that of the second sounds, while in some cases its feebleness 
makes the second sounds seem accented by comparison. Soft blow- 
ing systolic murmurs may develop at the pulmonary orifice, less 
often at the apex or over the aortic valve. 

The apex impulse becomes progressively feebler and more like 
a tap than a push. Irregularity and increasing rapidity are omi- 
nous signs which may be appreciated in the radial pulse, but still 
better by auscultation of the heart itself. In most of the acute in- 
fections evidence of dilatation of the weakened cardiac chambers is 
rarely to be obtained during life (although at autopsy it is not in- 
frequently found), 1 but in acute articular rheumatism an acute dila- 
tation of the heart appears to be a frequent complication, independ- 

1 Henchen's recent monograph on this subject, "Ueberdie acute Herzdila- 
tation bei acuten Infectionskrankheiten," Jena, 1899, does not seem to me 
convincing. 

17 



258 Physical diagnosis. 

ent of the existence of any valvular disease. Attention has been 
especially called to this point by Lees and Boynton {British Med. 
Jour., July 2, 1898) and by S. West. 

Influenza is also complicated not infrequently by acute cardiac 
dilatation. 

Chronic Myocarditis ( u Weakened Heart "J. 

Fatty or fibroid changes in the heart wall occurring in chronic 
disease are nsually the result of sclerosis of the coronary arteries 
and imperfect nutrition of the myocardium, but chronic toxaemias, 
like pernicious anaemia, may also produce a very high grade of fatty 
degeneration of the heart and especially of the papillary muscles. 

Whether fatty or fibroid changes predominate, the physical signs 
are the same. 

Physical Signs of Chronic Myocarditis. 

For the recognition of these changes in the myocardium our 
present methods of physical examination are always unsatisfactory 
and often wholly inadequate. Extensive degenerations of the 
heart wall are not infrequently found at autopsy when there has 
been no reason to suspect them during life. On the other hand, 
the autopsy often fails to substantiate a diagnosis of degeneration 
of the heart muscle, although all the physical signs traditionally 
associated with this condition were present during life. 1 To a con- 
siderable extent, therefore, our diagnosis of myocarditis must de- 
pend upon the history and symptoms of the case ; physical exami- 
nation can sometimes supplement these, sometimes not. Symptoms 
of cardiac weakness developing in a man past middle life, especially 
in a patient who shows evidences of arterio-sclerosis or high ar- 
terial tension, or who has suffered from the effects of alcohol and 
syphilis, suggest parietal disease of the heart, fatty or fibroid. 
The probability is increased if there have been attacks of angina 
pectoris, Cheyne-Stokes breathing, or of syncope. 

Inspection and palpation may reveal nothing abnormal, or there 

1 A well-known Boston pathologist recently told me that he had never 
known a case of myocarditis correctly diagnosed during life. 



PARIETAL DISEASE. 259 

may be an unusually diffuse, slapping cardiac impulse associated 
perhaps with a displacement of the apex beat to the left and down- 
ward. Marked irregularity of the heart beat, both in force and in 
rhythm, is sometimes demonstrable by these methods, and an in- 
crease in the area of cardiac clulness may be demonstrable in case 
dilatation has followed the weakening of the heart wall. Ausculta- 
tion may reveal nothing abnormal except that the aortic second 
sound is unusually sharp ; in some cases feeble and irregular heart 
sounds are heard, although the first sound at the apex is not infre- 
quently sharp. Reduplication of one or both sounds and disturb- 
ance of rhythm, especially the "gallop rhythm," are not infre- 
quent. If the mitral sphincter is dilated, or the papillary muscles 
are weakened, as not infrequently happens, we may have evidences of 
mitral regurgitation, a systolic murmur at the apex heard in the left 
axilla and. back with accentuation of the pulmonic second sound. 

Summary. 

1. The history and symptoms of the case or the condition of 
other organs are often of more diagnostic value than is the physical 
examination of the heart itself, which may show nothing abnormal. 

2. Among the rather unreliable physical signs, those most often 
mentioned are : 

(a) Weakness and irregularity of the heart sounds. 

(b) Accentuation of the aortic second sound. 

(c) A diffuse slapping cardiac impulse. 

(d) Reduplication of some of the cardiac sounds (gallop 
rhythm). 

(e) Evidences of cardiac dilatation. 

(/) Murmurs— especially the murmur of mitral insufficiency 
which often occurs as a result of dilatation of the valve orifices and 
weakening of the cardiac muscle. 



Differential 

We have to distinguish myocarditis from — 

(a) Uncomplicated valvular lesions. 

(b) Cardiac neuroses. 



260 PHYSICAL DIAGNOSIS. 

(a) It has been already pointed ont that valvular lesions do not 
necessarily give rise to any murmurs when compensation has failed. 
Under such circumstances one hears only irregular and weak heart 
sounds, as in myocarditis. The history of a long-standing valvu- 
lar trouble, a knowledge of the previous existence of murmurs, the 
age, method of onset, and symptoms of the case may assist us in 
the diagnosis. Cases of myocarditis are less likely to be associated 
with extensive dropsy than are cases of valvular disease whose com- 
pensation has been ruptured. 

(b) Weakness and irregularity of the cardiac sounds, when due 
to nervous affection of the heart and unassociated with parietal or 
valvular changes, is usually less marked after slight exertion. The 
heart "rises to the occasion" if the weakness is a functional one. 
On the other hand, if fatty or fibroid changes are present, the signs 
and symptoms are much aggravated by any exertion. 

In some cases of myocarditis the pulse is excessively slow and 
shows no signs of weakness. This point will be referred to again 
in the chapter on Bradycardia. 

Fatty Overgrowth. 

An abnormally large accumulation of fat about the heart may 
be suspected if, in a very obese person, signs of cardiac embarrass- 
ment (dyspnoea, palpitation) are present, and if on examination we 
find that the heart sounds are feeble and distant but preserve the 
normal difference from each other. When the heart wall is seri- 
ously weakened (as in the later weeks of typhoid), the heart sounds 
become more alike owing to the shortening of the first sound. 

In fatty overgrowth this is not the case. 

The diagnosis, however, cannot be positively made. We sus- 
pect it under the conditions above described, but no greater cer- 
tainty can be attained. 

Fatty Degeneration. 

There are no physical signs by which fatty degeneration of the 
heart can be distinguished from other pathological changes which 
result in weakening the heart walls. An extensive degree of fatty 



CARDIAC NEUROSES. 261 

degeneration is often seen post mortem in cases of pernicious anaemia, 
although the heart sounds have been clear, regular, and in all re- 
spects normal during life. The little we know of the physical 
signs common to fatty degeneration and to other forms of parietal 
disease of the heart has been included m the section on Myocar- 
ditis (see p. 257). 

Cardiac Neuroses. 
Tachycardia (Rapid Heart). 

Simple quickening of the pulse rate, or tachycardia, which may 
pass altogether unnoticed by the patient himself, is to be distin- 
guished from palpitation, in which the heart beats, whether rapid 
or not, force themselves upon the patient's attention. 

The pulse rate may vary a great deal in health. A classmate 
of mine at the Harvard Medical School had a pulse never slower 
than 120, yet his heart and other organs were entirely sound. Such 
cases are not very uncommon, especially in women. Temporarily 
the pulse rate may be greatly increased, not only by exercise and 
emotion, but by the influence of fever, of gastric disturbances, or of 
the menopause. Such a tachycardia is not always of brief duration. 
The effects of a great mental shock may produce an acceleration of 
the pulse which persists for days or even weeks after the shock. 

Among organic diseases associated with weakening of the pulse 
the commonest are those of the heart itself. Next to them, exoph- 
thalmic goitre, tumors or hemorrhage in the medulla, and obscure 
diseases of the female organs of generation, are the most frequent 
causes of tachycardia. 

The only form of tachycardia which is worthy to be considered 
as a more or less independent malady is 

Paroxysmal Tachycardia. 

As indicated in the name, the attacks of this disease are apt to 
begin and to cease suddenly. They may last a few hours or several 
days. The pulse becomes frightfully rapid, often 200 per minute or 
more. Bristowe records a case with a pulse of 308 per minute. 



262 PHYSICAL DIAGNOSIS. 

In the radial artery the pulse beat may he impalpable The heart 
sounds are regular and clear, but the diastolic pause is shortened and 
the first sound becomes short and "valvular," resembling the sec- 
ond ("tic-tac heart"). The paroxysm may be associated with 
aphasia and abnormal sensations in the left arm. Occasionally the 
heart becomes dilated, and oedema of the lungs, albuminuria, and 
other manifestations of stasis appear. As a rule, however, paroxys- 
mal tachycardia can be distinguished from the rapid heart-beat 
associated with cardiac dilatation by the fact that the heart remains 
perfectly regular. This same fact also assists us in excluding the 
cardiac neuroses due to tobacco, tea, and other poisons. From the 
tachycardia of Graves' disease the affection now in consideration 
differs by its paroxysmal and intermittent character. 

Bradycardia (Slow Heart). 

In many healthy adults the heart seldom beats over 50 times a 
minute . 

I. Among the causes which may produce for a short time an 
abnormally slow heart-beat are : 

(a) Exhaustion; for example, after fevers, after parturition, or 
severe muscular exertion. 

(b) Toxcemia; for example, jaundice, uraemia, auto-intoxications 
in dyspepsia. 

(c) In certain hysterical and 'melancholic states and in neurotic 
children, the pulse may be exceedingly slow. Pain has also a ten- 
dency to retard the pulse. 

(d) An increase of intracranial pressure, as in meningitis, cere- 
bral hemorrhage, depressed fracture of the skull. Possibly in this 
category belong the cases of bradycardia sometimes seen in epilep- 
tiform or during syncopal attacks. Bradycardia from any one of 
these causes is apt to be of comparatively short duration. 

II Permanent bradycardia is most often associated with coro- 
nary sclerosis and myocarditis. In this disease the pulse may re- 
main below 40 for months or years, though strong and regular, yet 
the patient may be free from disagreeable symptoms of any kind. 
The rate of the heart-beat cannot always be estimated by counting 



CARDIAC NEUROSES. 263 

the radial pulse. Not infrequently many pulsations of the heart 
are not of sufficient force to transmit a wave to the radial artery, 
and the mistake should never be made of diagnosing bradycardia 
simply by counting the radial pulse. 

Arrhythmia. 

1. Physiological Arrhythmia. — Arrhythmia, or irregularity in the 
force or rhythm of the heart-beat, is to a certain extent physiologi- 
cal. The heart normally beats a little faster and a little more strongly 
during inspiration than during expiration. Any psychical disturb- 
ance or muscular exertion may produce irregularity as well as a 
quickening of the heart-beat. Earely the pulse may be irregular 
throughout life in perfectly healthy persons. This irregularity is 
usually of rhythm alone; every second or third beat may be regu- 
larly omitted without the individual knowing anything about it or 
feeling any disagreeable symptoms connected with it. More rarely 
the heart's beats may be permanently irregular in force as well as 
rhythm despite the absence of any discoverable disease. 

In children the pulse is especially apt to be irregular, and dur- 
ing sleep some children show that modification of rhythm known 
as the "paradoxical pulse," which consists in a quickening of the 
pulse with diminution in volume during inspiration. 

(2) If we leave on one side diseases of the heart itself, patho- 
1 ogical arrhythmia is most frequently seen in persons who have used 
Wbacco or tea to excess, or in dyspepsia. In these conditions it is 
often combined with palpitation and becomes thereby very distress- 
ing to the patient. In connection with cardiac disease the follow- 
ing types of arrhythmia may be distinguished : 

(a) Paradoxical Pulse. — Any cause which leads to weakening 
of the heart's action may occasionally be associated with paradoxical 
pulse. Fibrous pericarditis has been supposed to be frequently 
associated with this type of arrhythmia, but if so it is by no means 
its only cause. 

(b) The bigeminal pulse is seen most frequently in cases of un- 
compensated heart disease (particularly mitral stenosis) after the 
administration of digitalis. Every other beat is weak or abortive 



264 PHYSICAL DIAGNOSIS. 

and is succeeded by an unusually long pause. Sometimes every 
third beat is of the abortive type, or an unusually long interval 
may divide the heart-beats into groups of three ("trigeminal 
pulse"). 

(c) Embryocardia, or the "tic-tac heart," represents a shorten- 
ing of the diastolic pause and of the first sound of the heart so that 
it resembles the second sound, as in the foetal heart. Any case of 
uncompensated heart disease, whether valvular or parietal, may be 
associated with this disturbance of rhythm. 

(d) The gallop rhythm. 

Owing to a reduplication of one of the heart sounds (usually 
the second), we may have three sounds instead of two with each 
beat of the heart, the sounds possessing a rhythm which reminds us 
of the hoof -beats of a galloping horse (see p. 181). This rhythm is 
heard especially in the failing heart of interstitial nephritis or cor- 
onary sclerosis. 

(e) Delirium cordis is a term used to express any great irregu- 
larity and rapidity of the heart-beats which cannot be reduced to 
a single type or rhythm. It is seen in the gravest stages of uncom- 
pensated heart disease. 

Palpitation. 

Defined by Osier as "irregular or forcible heart action percep- 
tible to the individual." The essential point is that the individual 
becomes conscious of each beat of his heart, whether or no the heart 
action is in any way abnormal. 

(a) In irritable conditions of the nervous system, such as occur 
at puberty, at climacteric, or in neurasthenic persons, palpitation 
may be very distressing. Temporary disturbances, such as fright, 
may produce a similar and more or less lasting effect. 

(b) The effect of high altitudes, or of even a moderate eleva- 
tion (1,500 feet) is sufficient to produce in many healthy persons a 
quickening and strengthening of the heart's action, so that sleep 
may be prevented. After a few nights this condition usually 
passes off, provided the heart is sound. 

(c) Abuse of tobacco and tea have a similar effect. 



CONGENITAL HEART DISEASE. 265 

Auscultation of a palpitating heart shows nothing more than 
unusually loud and ringing heart sounds, but since palpitation is 
often associated with arrhythmia of one or another type we must be 
careful to exclude the palpitation symptomatic of acute dilatation 
of the heart, such as may occur in debilitated persons after violent 
or unusual exertion. In this condition the area of cardiac dulness 
is increased and dyspnoea upon slight exertion becomes marked. It 
goes without saying that in almost any case of organic disease of 
the heart palpitation may be a very marked and distressing symp- 
tom. 

CONGENITAL HEAKT DISEASE. 

From the time of birth it is noticed that the child is markedly 
and permanently cyanosed, hence the term "blue baby." Dyspnoea 
is often, though not always, present, and may interfere with suck- 
ing. The cyanosis is practically sufficient in itself for the diag- 
nosis. 

Among congenital diseases of the heart the commonest and the 
most important (because it is less likely than any of the others to 
prove immediately fatal) is : 

1. Pulmonary Stenosis. 

This lesion is usually the result of foetal endocarditis, and is 
often associated with malformations and defects, such as patency 
of the foramen ovale and persistence of the ductus arteriosus. The 
physical signs of pulmonary stenosis are : 

(a) A palpable systolic thrill most distinct in the pulmonary 
area. 

(b) A loud murmur (often rough or musical) heard best in the 
same region, but usually transmitted to all parts of the chest. 

(c) A weak or absent pulmonic second sound. 

(d) An increased area of cardiac dulness corresponding to the 
right ventricle. 

Unlike most other varieties of congenital heart disease, pulmo- 
nary stenosis is compatible with life for many years, and "blue 
babies " with this lesion may grow up and enjoy good health, al- 



266 PHYSICAL DIAGNOSIS. 

though usually subject to pulmonary disorders (pneumonia or tu- 
berculosis).. For a discussion of the differential diagnosis of this 
lesion, see above, p. 252. 

2. Defects in the Ventricular Septum. 

The loud systolic murmur produced by the rush of blood through 
an opening between the ventricles is heard, as a rule, over the whole 
precordia. Its point of maxinium intensity differs in different 
cases, but is hardly ever near the apex of the heart. The most im- 
portant diagnostic point is the absence of a palpable thrill. With 
almost every other form of congenital heart disease in which a loud 
murmur is audible, there is a thrill as well. Hypertrophy of both 
ventricles may be present, but is seldom marked in uncomplicated 
cases. 

(Patency of the foramen ovale, if unassociated with other de- 
fects, does not usually produce any murmur or other signs by which 
it can be recognized during life, and causes no symptoms of any 
kind.) 

3. Persistence of the Ductus Arteriosus. 

The most characteristic sign is a loud, vibratory systolic mur- 
mur with its intensity at the base of the heart and unassociated with 
hypertrophy of either ventricle. If complicated with stenosis at or 
close above the pulmonary valves, persistence of the ductus arte- 
riosus cannot be diagnosed, as the murmur produced by it cannot 
with certainty be distinguished from that of the pulmonary ste- 
nosis, and the presence of hypertrophy of the right ventricle de- 
prives us of the one relatively characteristic mark of a patent arte- 
rial duct. 

It has been claimed that a murmur persisting through systole 
and into diastole is diagnostic of an open arterial duct, but this 
supposition is not borne out by post-mortem evidence. 

The signs produced by the other varieties of congenital heart 
disease, such as aortic stenosis and tricuspid or mitral lesions, do 
not differ materially from those characterizing those lesions in 



CONGENITAL HEART DISEASE. 267 

adults. Excluding these, we may summarize the signs of the othei 
lesions as follows : 

(a) Practically all cases of congenital heart disease, which pro- 
duce any physical signs beyond cyanosis and dyspnoea, manifest 
themselves by a loud systolic murmur heard all over the precordia 
and often throughout the chest. Its maximum intensity is usually 
at or near the base of the heart. 

(b) If there is no thrill and no hypertrophy, the lesion is prob- 
ably a defect in the ventricular septum. 

(c) If there is a thrill but no hypertrophy, the lesion is probably 
a patent ductus arteriosus. 

(d) If there is a thrill and hypertrophy of the right ventricle, 
the lesion is probably pubnonic stenosis, especially if the pulmonie 
second sound is feeble. 



CHAPTER XII. 

DISEASES OF THE PERICABDIUM. 

I. Pericarditis. 

Three forms are recognized clinically : 

(1) Plastic, dry, or fibrinous pericarditis. 

(2) Pericarditis with, effusion (serous or purulent). 

(3) Pericardial adhesions or adherent pericardium. 
Fibrinous pericarditis may be fully developed without giving 

rise to any physical signs that can be appreciated during life. In 
several cases of pneumonia in which I suspected that pericarditis 
might be present, I have listened most carefully for evidences of 
the disease and been unable to discover any ; yet at autopsy it was 
found fully developed — the typical shaggy heart. We have every 
reason to believe, therefore, that pericarditis is frequently present 
but unrecognized, especially in pneumonia and in the rheumatic at- 
tacks of children. On the other hand, it may give rise to very 
marked signs which are the result of — 

(a) The rubbing of the roughened pericardial surfaces against 
one another when set in motion by the cardiac contractions. 

(p) The presence of fluid in the pericardial sac. 

(c) The interference with cardiac contractions brought about by 
obliteration of the pericardial sac together with the results of ad- 
hesions between the pericardium and the surrounding structures. 

(1) Dry or Fibrinous Pericarditis. 

The diagnosis rests upon a single physical sign — "pericardial 
friction " — which is usually to be appreciated by auscultation alone, 
but may occasionally be felt as well. Characteristic pericardial 
friction is a rough, irregular, grating or shuffling sound which oc- 



DISEASES OF THE PERICARDIUM. 



269 



curs irregularly and interruptedly during the larger part of each 
cardiac cycle. It is almost never accurately synchronous either 
with systole or diastole, but overlaps the cardiac sounds, and en- 
croaches upon the pauses in the heart cycle. It is seldom exactly 
the same in any two successive cardiac cycles and differs thereby 
from sounds produced within the heart itself. Pericardial friction 
seems very near to the ear and may often be increased by pressure 




Pericardial friction. 



Fig. 147.— Snowing Most Frequent Site of Audible Pericardial Friction. 



with the stethoscope ; it is not materially influenced by the respi- 
ratory movements. 

It is best heard in the majority of cases in the position shown 
in Fig. 147 ; that is, over that portion of the heart which lies near- 
est to the chest wall and is not covered by the margins of the lungs ; 
but not infrequently it may be heard at the base of the heart or 
over the whole precordial region. The sounds are fainter if the 
patient lies on the right side, and sometimes intensified if, while 
sitting or standing, he leans forward and toward the left, so as to 
bring the heart into closer apposition with the chest wall. 

Pericardial friction sounds often change rapidly from hour 
to hour, and may disappear and reappear in the course of a 
day. 



270 PHYSICAL DIAGNOSIS. 

In rare eases the friction may occur only during systole or only 
during diastole. In such cases the diagnosis between pericardial 
and intracardial sounds may be very difficult. 

Differential Diagnosis. 

(a) Pleuro- Pericardial Friction. 

Fibrinous inflammation affecting that part of the pleura which 
overlaps the heart may give rise to sounds altogether indistinguish- 
able from those of true pericardial friction when the inflamed pleu- 
ral surfaces are made to grate against one another by the move- 
ments of the heart. Such sounds are sometimes increased in 
intensity during forced respiration and disappear at the end of 
expiration, while true pericardial friction is usually best heard if 
the breath is held at the end of expiration. If a friction sound 
heard in the pericardial region ceases altogether when the breath 
is held, we may be sure that it is produced in the pleura and not 
in the pericardium, but in many cases the diagnosis cannot be made 
correctly. 

(Z>) Intracardiac Murmurs. 

From murmurs due to valvular disease of the heart, pericardial 
friction can usually be distinguished by the fact that the sounds to 
which it gives rise do not accurately correspond either with systole 
or diastole, and do not occupy constantly any one portion of either 
of these periods. Cardiac murmurs are more regular, seem less 
superficial, and vary less with position and from hour to hour. 
Pressure with the stethoscope does not increase so considerably the 
intensity of intracardiac murmurs. When endocarditis and peri- 
carditis occur simultaneously, it may be very difficult to distinguish 
the two sets of sounds thus produced. The pericardial friction is 
usually recognized with comparatively little difficulty, but it is 
hard to make sure whether in addition we hear endocardial mur- 
murs as well. 



DISEASES OF THE PERICARDIUM. 



271 



(2) Pericardial Effusion. 

Following the fibrinous exudation, which roughens the pericar- 
dial surface and produces the friction sounds just described, serum 
may accumulate in the pericardial sac. Its quantity may exceed 
but slightly the amount of fluid normally present in the pericar- 




FiG. 148.— Pericardial Effusion, Cardie-hepatic Angle obtuse. (From v. Ziemssen's Atlas.) 



dium, or may be so great as to embarrass the cardiac movements 
and finally to arrest them altogether. In chronic (usually tubercu- 
lous) cases, the pericardium may become stretched so as to hold a 
quart or more without seriously interfering with the heart's action, 
while a much smaller quantity, if effused so rapidly that the peri- 
cardium has no time to accommodate itself by stretching, will prove 
rapidly fatal. 



272 PHYSICAL DIAGNOSIS. 

Hydropericardiuni denotes a dropsy of the pericardium occur- 
ring by transudation as part of a general dropsy in cases of renal 
disease or cardial weakness. The physical signs to which it gives 
rise do not differ from those of an inflammatory effusion, and, ac- 
cordingly, all that is said of the latter in the following section may 
be taken as equally an account of the signs of hydropericardiuni. 

Haemopericardium, or blood in the pericardial sac, due to stabs 
or to ruptures of the heart, is usually so rapidly fatal that no 
physical signs are recognizable. 

Physical Signs of Pericardial Effusion. 

In most cases a pericardial friction rub has been observed prior 
to the time of the fluid accumulation. The presence of fluid in the 
pericardial sac is shown chiefly in three ways : 

(1) By percussion, which demonstrates an area of dulness more 
or less characteristic (see below). 

(2) By auscultation, which may reveal an unexpected feebleness 
in the heart sounds when compared with the power shown hi the 
radial pulse. 

(3) By the signs and symptoms of pressure exerted by the peri- 
cardial effusion upon surrounding structures. 

Bulging of the precordia is occasionally to be seen in children j 
in adults we sometimes observe a flattening of the interspaces just 
to the right of the sternum between the third and sixth ribs. 

(1) The Area of Percussion Dulness. — The extent of the dull 
area depends not only on the size of the effusion and the position of 
the patient, but also on the amount of "give" in the pericardium 
and in the lungs as well as on the size of the lingula pulmonalis. 
Allowing for these uncertain factors, we may say: («) One of the 
most characteristic points is the unusual 1 extension of the percus- 
sion dulness a considerable distance to the left and beyond the car- 
diac impulse. (5) Next to this, it is important to notice a change 
in the angle made by the junction of the horizontal line correspond- 

1 In health the cardiac dulness extends about three-fourths of an inch be- 
yond the cardiac impulse, but in pericardial effusion the difference is greater. 



DISEASES OF THE PERICARDIUM. 



273 



ing to the upper limit of hepatic clulness and the nearly perpendicu- 
lar line corresponding to the right border of the heart. In health 
this cardio-hepatic angle is approximately a right angle; in pericar- 
dial effusion it is much more obtuse (see Fig. 149). Kotch has 
called attention to the importance of dulness in the fifth right inter- 
costal space as a sign of pericardial effusion, but a similar dulness 
may be produced by enlargement of the liver. 

Except for the two points mentioned above (the unusual exten- 
sion of the dulness to the left of the cardiac impulse and the blunting 
of the cardio-hepatic angle), there seems to me to be nothing charac- 
teristic about the area of dulness produced by pericardial effusion. 



Tympany, 




J.—- Dulness, 



" Cardiac impulse. 



Liver dulness. 



Fig. 149.— Percussion Dulness in Pericardial Effusion, with Tympanitic Resonance Under the 

Left Clavicle. 



The " pear-shaped " or triangular area of percussion dulness men- 
tioned by many writers has not been present in cases which have 
come under my observation. In large effusions percussion reso- 
nance may be diminished in the left back, and under the left clav- 
icle the percussion note may be tympanitic from relaxation of the 
lung. Traube's semilunar space may be obliterated, but this occurs 
also in pleuritic effusions. 

In some cases the area of dulness may be modified by change in 
the patient's position. After marking out the area of percussion 
18 



274 PHYSICAL DIAGNOSIS. 

dulness with the patient in the upright position, let him lie upon 
his right side. The right border of the area of dulness will some- 
times move considerably farther to the right. A dilated heart can 
be made to shift in a similar way, but to a lesser extent. Compar- 
atively little change takes place if the patient lies on his left side, 
and no important information is elicited by placing him flat on his 
back or by getting him to lean forward. 

Unfortunately, it is only with moderate-sized effusions occur- 
ring in a pericardial sac free from adhesions to the surrounding 
parts that this shifting can be made out. Large effusions may not 
shift appreciably, and less than 150 c.c. of fluid probably cannot be 
recognized by this or by any other method. But with large effu- 
sions the lateral extension of the area of dulness may be so great 
as to be almost distinctive in itself, i.e., from the middle of the left 
axilla nearly to the right nipple. 

(2) Feebleness of the heart sounds and of the apex impulse is of 
diagnostic importance only when it gradually takes the place of the 
normal phenomena as one watches the heart from day to day. 
Under these conditions they have some contirmatory value in the 
diagnosis of pericardial effusion. 

Broncho- vesicular breathing with increased voice sounds may 
be heard over the tympanitic area below the left clavicle and occa- 
sionally between the scapulae behind. This is a result of compres- 
sion of the lung. 

(3) Pressure exerted by the pericardial exudation upon sur- 
rounding structures may give rise to dyspnoea, especially of a 
paroxysmal type, to dysphagia, to aphonia, and to an irritating 
cough. The "paradoxical pulse," small and feeble during inspira- 
tion, is occasionally to be seen, but is by no means peculiar to this 
condition and has no considerable diagnostic importance. 

(4) Inspection and palpation usually help us very little, but two 
points are occasionally demonstrable by these methods : 

(a) A smoothing out of the intercostal depression in the precor- 
dial region, especially near the right border of the sternum between 
the third and the sixth ribs. 

(b) A progressive diminution of the intensity of the apex im- 
pulse until it may be altogether lost. If this change occurs while 



DISEASES OF THE PERICARDIUM. 275 

the patient is under observation, and especially if the apex impulse 
reappears or becomes more distinct when the patient lies on the 
right side, it is of considerable diagnostic value. In conditions 
other than pericardial effusion, the apex impulse becomes less visible 
in the right-sided decubitus. 

Differential Diagnosis. 

(1) Our chief difficulty is to distinguish the disease from hyper- 
trophy and dilatation of the heart. In the latter, which often com- 
plicates acute articular rheumatism with or without plastic pericar- 
ditis, the apex impulse is often very indistinct to sight and touch 
as in pericardial effusion. But the area of dulness is less likely to 
extend beyond the apex impulse to the left or to modify the cardio- 
hepatic angle, or to shift when the patient lies on the right side. 
Pressure symptoms are absent, and there are no areas of broncho- 
vesicular breathing with tympanitic resonance under the left clavicle 
or in the axilla. Yet not infrequently these differentiae do not 
serve us, and the diagnosis can be made only by puncture. 

(2) I have twice known cases of encapsulated empyema mistaken 
for pericardial effusion. In one case a needle introduced in the 
fifth intercostal space below the nipple drew pus from what turned 
out later to be a localized purulent pleurisy, but the diagnosis was 
not made until a rib had been removed and the region thoroughly 
explored. It is not rare for pleuritic effusions to gather first 
in this situation, viz., just outside the apex impulse in the left 
axilla. 

Such effusions may gravitate very slowly to the bottom of the 
pleural cavity or may become encapsulated and remain in their 
original and very deceptive position. In such cases the signs of 
compression of the left lung are similar to those produced by a 
pericardial effusion, and the results of punctures may be equivocal 
as in the case just mentioned. If there is any dulness, even a very 
narrow zone, in the left axilla between the fifth and eighth ribs, 
though there be none in the back, the likelihood of pleurisy should 
be suggested. 

As between pleuritic and pericardial effusion the presence of a 



276 PHYSICAL DIAGNOSIS. 

good pulse and the absence of marked dyspnoea favors the former. 
In the two cases above referred to in which encapsulated pleurisy 
was mistaken for pericarditis, the general condition of the patient 
struck me at the time as surprisingly good for pericarditis. 

If both pleurisy and pericarditis are present, the area of peri- 
cardial dulness is not characteristic until the pleuritic fluid has been 
drawn off. The persistence of dulness in the cardio-hepatic angle 
and beyond the apex beat after a left pleurisy has been emptied by 
tapping, and after the heart has had time to return to its normal 
position, should make us suspect a pericardial effusion. 

Despite the utmost care and thoroughness in physical examina- 
tion, many cases of pericardial effusion go unrecognized, especially 
in infants, in elderly persons, or when the lung borders are adher- 
ent to the pericardium or to the chest wall. 

In the rheumatic attacks of children, it should be remembered 
that pericarditis is even more common than endocarditis. 

Adherent Pericardium. 

In the majority of cases the diagnosis cannot be made during 
life, unless the pericardium is adherent, not only to the heart, but 
to the walls of the chest as well. When this combination of peri- 
carditis with chronic mediastinitis is present, the diagnosis may be 
suggested by 

(a) A systolic retraction of the chest wall in the region of the 
apex impulse, at the base of the left axilla and in the region of the 
eleventh and twelfth ribs in the left back (Broadbent's sign). Such 
retraction is more marked during a deep inspiration. (It should 
be remembered that systolic retraction of the interspaces in the 
vicinity of the apex is very commonly seen in cases of cardiac hy- 
pertrophy from any cause, owing to the negative pressure produced 
within the chest by the contraction of a powerful heart.) A quick 
rebound of the cardiac apex at the time of diastole (the diastolic 
shock) is said to be characteristic of pericardial adhesions, but is 
often absent. 

(b) Collapse of the cervical veins during diastole has been no- 
ticed by Friedreich, and the paradoxical pulse, above described, is 



DISEASES OF THE PERICARDIUM. 277 

said to be more marked in adherent pericardium than in any other 
known condition. Most recent writers, however, place no reliance 
upon it. 

(c) When the lungs are adherent to the pericardium or to the 
chest wall, as is not uncommonly the case, the absence of the phrenic 
phenomenon (Litten's signs) and of any respiratory excursion of 
the pulmonary margins may be demonstrated. Since pericardial 
adhesions are most often due to tuberculosis, the discovery of tu- 
berculosis in. the lung or elsewhere may be of aid in diagnosis. 

(d) Broadbent considers that the absence of any shift in the 
position of the apex beat, with respiration or change of patient's 
position, is an important point in favor of mediastino-pericarditis. 
In health and in valvular or parietal disease of the heart, the apex 
beat will swing from one to two inches to the left when the patient 
lies on his left side, and the descent of the diaphragm during full 
inspiration lowers the position of the cardiac impulse considerably, 

(e) The presence of hypertrophy or dilatation affecting espe- 
cially the right side of the heart, and not accounted for by the 
existence of any disease of the cardiac valves, of the lung, or of 
the kidney, should make us suspect pericardial and mediastinal 
adhesions. Such adhesions embarrass especially the right ven- 
tricle, because it is the right ventricle far more than the left which 
becomes attached to the chest wall. The left ventricle is more 
nearly free. 

(/) Since the space enclosed by the divergent costal cartilage 
just below the ensiform is but loosely associated with the cen- 
tral tendon of the diaphragm, Broadbent looks especially at this 
point for evidence of mediastinal or pericardial adhesions, the 
effect of which is to arrest completely the slight respiratory move- 
ments of this part of the abdominal wall. 

(g) Adherent pericardium, occurring as a part of a widespread 
chain of fibrous processes involving the pleura, the mediastinum, 
and the peritoneum, may give rise in young persons to a train of 
symptoms and signs suggesting cirrhosis of the liver. Ascites 
collects, the liver is enlarged, yet there are no signs in the heart, 
kidneys, or blood sufficient to explain the condition. In any 
such case adherent pericardium should be considered. Fig. 150 



278 



PHYSICAL DIAGNOSIS. 



show the appearance in cases of this kind in which the diagnosis 
was verified by autopsy. 





V, 



\ 



> \ 



I 



I 



C _. J L 



Fig. 150.— Adherent Pericardium, Ascites. 



Summary. 

The diagnosis of adherent pericardium with chronic inediastini 
tis is suggested by 



DISEASES OF THE PERICARDIUM. 



279 



(a) Systolic retraction of the lower intercostal spaces in the 
left axilla and in the left back, followed by a diastolic rebound. 

(b) The absence of any change in the position of the apex im- 
pulse with respiration or change of position. 

(c) The presence of hypertrophy and dilatation of the right 
ventricle without obvious cause. 

(d) The absence of any respiratory excursion of the lung bor- 
ders near the heart and of the abdominal wall at the costal angle. 

(e) The presence of signs like those of hepatic cirrhosis in a 
young person and without any obvious cause. 



i 



CHAPTER XIII. 

THORACIC ANEURISM. 
Aneurism of the Thoracic Aorta. 

For clinical purposes thoracic aneurisms may be divided into 
the diffuse and the saccular. Saccular aneurisms of the ascending 
or descending portion of the arch of the aorta are apt to penetrate 
the chest wall, while aneurism of the transverse aorta or diffuse 
dilatations of the whole aortic arch are more likely to extend within 
the chest without eroding the thoracic bones. Practically any 
aneurism which penetrates the thoracic bones may be inferred to 
be saccular, but if no such penetration takes place, it may be im- 
possible to make out whether the dilatation is diffuse or circum- 
scribed. I shall consider : 

I. The signs of the presence of aneurism. 

II. The evidences of its seat. 

Inspection and palpation give us most of the important informa- 
tion in the diagnosis of aneurism. The patient should be placed in 
the position shown in Fig. 151, so that the light will strike obliquely 
across the surface of the chest, and the observer should be so placed 
that his eyes are as nearly as possible at the level at that part of 
the chest at which he expects to see pulsation. 

In the majority of cases of aneurism some abnormal pulsation 
may be made out either to the right of the sternum in front or in 
Abnormal ^ ne region of the left scapula behind. If the aneur- 
Pulsation. ism is large, a considerable area of the chest wall may 
be lifted with each beat of the heart ; with smaller growths the 
pulsating area may be small and sharply circumscribed. Not in- 
frequently an abnormal pulsation at the sternal notch or in the 



THORACIC ANEURISM. 



281 



neck may be observed. Other causes of abnormal pulsations in 
the chest, such as dislocation or uncovering of the heart, must of 
course be excluded. Pulsations due to aneurism can sometimes 
be distinctly seen to occur later than the apex impulse of the heart. 

Palpation controls the results of inspection, but at times a pul- 
sation may be seen better than felt ; at others may be felt better 
than seen. Bimanual palpation — one hand over the suspected area 
in front and one in a corresponding position behind — is useful. 

If the aneurism involves the ascending portion of the aortic 




Fig. 151.— Position When Looking for Slight Aneurismal Pulsation. 



arch, it is likely sooner or later to erode the right margin of the 
sternum and the adjacent parts of the second or third costal car- 
tilages and appear externally as a round swelling in 
which a systolic pulsation is to be seen and felt. This 
pulsation is almost always distinctly expansile in character, and 
differs in this respect from the up-and-down motion which may 
be communicated to a tumor of the chest wall by the beating of 
a normal aorta. The tumor is usually firm, rarely soft, and may 
be as hard as any variety of malignant new growth. Occasionally 



282 



PHYSICAL DIAGNOSIS. 



the thickness of the lamellated clot within it is so great that no 
pulsations are transmitted to the surface. 

Whether the aneurism penetrates the chest or not, it is often 
possible to feel over it a vibrating thrill, usually sys- 
tolic in time. If the layer of lamellated clot in the 
sac is very thick, the thrill is less apt to be felt. 

More important in diagnosis is a diastolic shock or tap which is 
appreciated by laying the palm of the hand lightly over the affected 




Fig. 152.— Aneurismal Tumor (A). The arrow B points to a gummatous swelling near the en- 
siform cartilage. The radiographic appearances of this case are shown below (Fig. 155). 



area. This diastolic shock is due to the recoil of the blood in the di- 
lated aorta, and is one of the most important and characteristic signs 
Diastolic m aneurism. As the wall of the sac becomes weaker, 
Shock, the intensity of this shock diminishes. This diastolic 
shock may be appreciated over the trachea also, and is thought by 
some to have even more significance when felt hi this situation. 

Of special importance in aneurism of the transverse arch is the 
sign known as the tracheal tug. The arch of the aorta runs over 



THORACIC ANEURISM. 



283 



the left primary bronchus in such a way that when the aorta is 
dilated, the bronchus is pressed upon with each expansile pulsation 
Tracheal °f *he artery. This systolic pressure transmitted to 
Tug. the trachea produces a distinct downward tug upon it 
with each systole of the heart. The tug is best felt by making the 
patient throw back his head so as to put the trachea upon a stretch. 
The physician then stands behind him and gently presses the tips 
of the fingers of both hands up under the lower border of the cri- 




Fig. 153.— Aneurism Tumor Perforating the Sternum at A. At B there is a gummatous 
(See below, Fig. 155, a radiograph of this case). 



coid cartilage. In feeling thus for the tracheal tug as transmitted 
to the cricoid cartilage certain precautions must be observed : 

(a) One must distinguish the tracheal tug from a simple pulsa- 
tion transmitted to the superficial tissues by the vessels under- 
neath. Such pulsation makes the tissues move out and in rather 
than up and down. 

(b) A tracheal tug felt only during inspiration has no patho- 
logical significance and is frequently present in health. 

While preparing to try for the tracheal tug we may notice 
whether there is any dislocation of the trachea, as shown by the 



284 PHYSICAL DIAGNOSIS. 

displacement of Adam's apple. Aphonia, stridor, cough, dysphagia, 
and other symptoms are produced by pressure on gullet and windpipe. 
Other signs of aneurism, due to the pressure of the dilated aorta 
upon the nerves or vessels of the mediastinum, are : 

(1) Inequality of the pupils. 

(2) Inequality of the radial pulses. 

(3) (Edema and cyanosis of one arm or of one side of the neck 
and head. 

(4) Pain in one arm from the pressure of an aneurism involving 
the subclavian artery upon the brachial plexus. 

(5) Clubbing of the fingers of one hand (rare). 

(6) Prominence of one eye (rare). 

(7) Flushing or sweating of one side of the face (very rare). 
Contraction or dilatation of the pupil is due to an irritative or 

paralytic affection of the sympathetic nerves. This symptom is 
much commoner than the other effect of pressure upon the sympa- 
thetic nerves ; namely, flushing or sweating of one side of the face. 

In comparing the pulses in the two radials we must bear in mind 
the possibility of a congenital difference between them, due to a 
difference either in the size of the arteries or in their position, and 
also that a tumor pressing on the subclavian may affect the pulse 
exactly as an aneurism. The pulse wave upon the affected side 
(most often the left) may be either less in volume or later in time 
than the wave in the other radial artery, according as the pulse 
wave is actually delayed in the aneurismal sac or merely diminished 
by it. In marked cases the pulse upon the affected side may be 
nearly or quite absent. On the other hand the inequality of the 
pulses may be so slight that the sphygmograph has to be employed 
to demonstrate differences in the shape of the wave not perceptible 
to the fingers. 

Examination of the heart itself may show some dislocation of 
the organ to the left and downward, owing to the direct nressure 
of the aneurismal sac, but no enlargement. 

II. Percussion. 

If the aneurism is deep-seated, the results of percussion are 
negative. If, on the other hand, it 1 be situated immediately be- 






THORACIC ANEURISM. 



285 



neath the sternum or close under the thoracic wall, an area of dull- 
ness, not present in the normal chest, may be mapped out. The 
outlines most commonly seen in such cases are shown in Fig. 154. 
"When the aneurism involves the descending aorta, an area of dulness 
may be found in the region of the left scapula or below it, and pul- 
sation may be detected in the same area. 

III. Auscultation. 

The signs revealed by auscultation are not of much diagnostic 
value as a rule. In about one-half of the cases of sacculated aneu- 



Aneurismal 
dulness. ' 




Heart dulness. 



Liver dulness.. - 



Fig. 154.— Diagram of Percussion Dulness in Aortic Aneurism. 

rism there are no sounds or murmurs to be heard over the tumor. 
In other cases a systolic murmur, the audible counterpart of the 
vibratile thrill, may be heard over the area of pulsation, tumor, or 
dulness corresponding to the aneurismal sac. This systolic mur- 
mur may be due to many causes other than aneurism, and has noth- 
ing characteristic about it. A similar systolic sound is sometimes 
heard over the trachea (Drummond's sign) or in the mouth, if the 
patient closes his lips around the pectoral extremity of the steth- 
oscope (Sansom's sign). 

A loud, low-pitched diastolic sound, corresponding to the pal- 



286 



PHYSICAL DIAGNOSIS. 



pable diastolic shock, is generally to be heard in the aortic region. 
This diastolic sound, which is probably not produced by the aortic 
valves, is remarkably deep-toned and loud, and is, on the whole, the 
most important sign of aneurism revealed by auscultation. 

If a portion of either lung is directly pressed upon by the an- 
eurismal sac, we may have the signs of condensation of the lung 
in the area pressed upon (slight dulness, broncho-vesicular breath- 
ing, and exaggerated voice sounds). If one of the primary bronchi 



From the front. 



From behind. 




Fig. 155.— Radiograph of Case whose Photograph is Reproduced as Figs. 152 and 153. In the 
right-hand cut are shown the appearances seen from behind. The left-hand cut, At A, 
aneurismal sac ; B, heart displaced ; C, liver (not in focus). 



is pressed upon, as occasionally happens, atelectasis of the corre- 
sponding lung may be manifested by the usual signs (dulness, ab- 
sence of tactile fremitus and of respiratory and vocal sounds). 

Since aneurism is frequently associated with regurgitation at 
the aortic valve, a diastolic murmur is not infrequently to be 
heard. 

If the aneurismal sac is of very great size, the pulse wave in 
the femorals may be obliterated, as happened in a case described 
by Osier. 



THORACIC ANEURISM. 



287 



IV. Radioscopy. 

With the fluoroscope and through photography one can often 
make out a shadow corresponding to the position of the aneurism. 




Fig. 156— Aortic Aneurism. (From v. Ziemssen's Atlas.) 



The position of the shadow is best explained by reference to Figs c 
155, 156, and 157. 

Summary. 

The most important signs of aneurism are : 

1. Abnormal pulsation — visible or palpable 

2. Tumor over which a 

3. Thrill and a 



288 PHYSICAL DIAGNOSIS. 

4. Diastolic shock may be felt. 

5. Tracheal tug. 

6. Pressure signs (unequal pulses, pupils, hoarseness, pain, etc.). 

7. Dulness on percussion over the suspected area. 

8. Loud, low-pitched aortic second sound. 

9. Systolic murmur (least important of all). 




Fig. 157.— Aneurism of the Aorta. (Curschman.) 



10. Radioscopy may demonstrate a shadow higher up than that 
corresponding to the heart and extending beyond that produced by 
the sternum, spinal column, and great vessels. 

Diagnosis of the Seat of the Lesion. 

(a) Aneurism of the ascending arch generally approaches or 
penetrates the chest wall in the vicinity of the second right inter- 
costal space near the sternum. Previous to perforating the thoracic 



THORACIC ANEURISM. 289 

parietes, the growth of the aneurism may give rise to pain, pulsa- 
tion, and dulness and thrill in this region. 

(b) Aneurism of the transverse arch or diffuse dilatation of the 
aorta, such as usually occurs in long-standing cases of aortic regur- 
gitation, may not give rise to any visible pulsation of the chest 
wall, and, if deep-seated, need not produce any abnormal dulness 
on percussion. In such cases an aneurism is to be recognized, if 
at all, by evidences of pressure on the nerves or vessels of the medi- 
astinum (cough, aphonia, inequality of the pupils, tracheal tug, 
etc.). 

(c) Aneurism of the descending aorta gives rise usually to severe 
and persistent pain in the back, which radiates along the intercos- 
tal nerves or downward. Other pressure symptoms are not marked, 
but in advanced cases an area of abnormal dulness and pulsation 
may be found in the region of the left scapula or below it. 

(d) If the innominate artery or one of the carotids is involved, 
we usually find a pulsating lump in the region of one or the other 
claviculo-sternal joint or at the root of the neck, and the trachea 
may be displaced to one side. If the subclavian is involved or 
pressed upon, there may be pain and oedema in the corresponding 
arm. 

Differential Diagnosis. 

(a) Some writers draw a distinction between the diffuse dilata- 
tion of the aortic arch, which sooner or later complicates almost 
every case of incompetency of the aortic valves, and saccular aneu- 
rism of the transverse portion of the aorta. Clinically, such dis- 
tinction seems to be impossible, although if symptoms resembling 
those of aneurism gradually develop in a case of aortic regurgita- 
tion, one may suspect that the dilatation of the aorta is merely 
part of the distention of the whole arterial tree, which aortic regur- 
gitation tends to produce. 

(b) Aneurism is not infrequently mistaken for aortic stenosis, in 
which a systolic murmur and thrill, similar to those occurring in 
aneurism, are to be heard over the region of the aortic arch. From 
aortic stenosis aneurism is distinguished by the fact that it does 

19 



290 PHYSICAL DIAGNOSIS. 

not produce characteristic changes in the pulse, and by the presence 
of some one of the symptoms above described, such as tracheal 
tug, pressure symptoms, abnormal area of percussion dulness, etc. 

(c) Simple dynamic throbbing of a normal aortic arch similar 
to that which occurs in the abdominal aorta may lift the chest wall 
so as to simulate aneurism. The other positive symptoms and 
signs of aneurism are, however, absent. 

(d) Pulmonary tuberculosis or cancer of the oesophagus, produc- 
ing as they may substernal pain, cough, and aphonia by pressure 
upon mediastinal structures, have been mistaken for aneurism, 
from which, however, they may be distinguished by the absence of 
the positive signs above described, by the more rapid emaciation 
of the patient, and by the positive evidences of cancer or tubercu- 
losis. 

(e) Empyema necessitatis may produce a pulsating tumor like 
that of aneurism and the area of dulness may be similar, but there 
is no diastolic shock, no tactile thrill or murmur, and the history 
of the case is usually very different from that of aneurism. It is 
perfectly safe to insert a fine hollow needle in doubtful cases. No 
serious hemorrhage results if aneurism is present, and the diagnosis 
and treatment may be greatly assisted. 

(/) Mediastinal tumors are sometimes almost indistinguishable 
from aneurism during life. They may produce a more intense and 
widespread dulness which is usually in the median line, while the 
dulness of aneurism is oftener at one side. The pulsation transmit- 
ted to a tumor by the heart has not the expansile character of aneu- 
rismal pulsation. Tumors are not associated with any diastolic 
shock, rarely with a tracheal tug. 

The course of most mediastinal tumors is progressive and at- 
tended by great cachexia, while the symptoms of aneurism are often 
more or less intermittent, and unless pain i 3 severe there is no such 
emaciation or anaemia as is commonly seen with mediastinal tu- 
mors. Pressure symptoms may be the same in both diseases, but 
are usually more marked with mediastinal growths. A metastatic 
nodule over the clavicle sometimes betrays the presence of a pri- 
mary focus within the chest. 



THORACIC ANEURISM. 291 

(g) Retraction of the right lung (fibroid phthisis), with or without 
displacement of the heart toward the diseased side, may uncover 
the heart so as to produce some of the signs of aneurism, i.e., pul- 
sation and dulness in the upper right intercostal spaces near the 
sternum, with a loud aortic second sound and sometimes a systolic 
murmur hi the dull area.. 

The history of the case and a careful examination of the lungs 
usually suffice to set us right. 

(h) Dilatation of the heart may be so extreme that pulsation 
and percussion dulness appear in the characteristic aneurismal area 
to the right of the sternum, especially if there is solidification of 
the left lung. But the pulse is in such cases much weaker and 
more irregular than is to be expected in uncomplicated cases of aortic 
aneurism, and the history of the case is usually decisive. 



CHAPTER XIV. 
DISEASES OF THE LUNGS. 

BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 

I. Tracheitis. 
In connection with bronchitis or as a forerunner thereof, inflam- 
mation of the trachea is not uncommon. It gives rise to no char- 
acteristic physical signs, but is to be suspected when the patient 
complains of cough with pain over the upper portion of the sternum. 

Bronchitis. 

Inflammation of the larger bronchial tubes is not often the 
cause of any definite physical signs, but with every paroxysm of 
coughing the patient may feel pain in an area corresponding ex- 
actly to the anatomical position of the primary bronchi. I have 
seen patients indicate most accurately the situation of the large 
tubes when pointing out the position of pain produced by coughing. 

In the vast majority of cases of acute bronchitis the smaller 
bronchi are involved, and the swelling of their walls, with or with- 
out exudation, is manifested by the following physical signs : 1 

(1) Diminution in the intensity of vesicular breathing over the 
area affected (rarely in the earliest stages the breath sounds are 
exaggerated and harsh, especially in the upper portions of the 
chest). 

1 Bronchitis may exist without rales, but cannot be diagnosed without 
them. Occasionally they are present only in the early morning. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 293 

(2) Bales, which are squeaking or piping over bronchi which 
are narrowed without any considerable amount of exudation, as is 
the case in the earliest stages of many cases, and bubbling, crack- 
ling, or clicking in later stages, when watery or viscid exudation is 
present in the tubes. The calibre of the bronchi affected can be 
estimated from the coarseness or fineness of the rales. Low-pitched 
groaning sounds point to a stenosis of a relatively large bronchus, 
while squeaking and whistling sounds are usually produced in the 
smaller tubes. Large, bubbling rales are much less often heard 
than the finer, crackling variety. The latter are produced in the 
smallest tubes, the former in the larger variety. 

Simple non-tuberculous bronchitis is almost invariably bilateral 
or symmetrical, and affects most often the lower two-thirds of the 
lungs, leaving the apices relatively free. It is almost never con- 
fined to an apex. When rales are to be heard on one side of the 
chest only, and when they persist in the same spot for days and 
weeks, tuberculosis is always to be suspected, especially if the 
rales are localized at the summit of one or both lungs. It should 
never be forgotten that the tubercle bacillus is capable of exciting 
a bronchitis indistinguishable from other varieties of bronchitis, 
except by its tendency to show itself at the apex of the lung and 
on one side only ; most cases of pulmonary tuberculosis begin in 
this way. 

The only other variety of bronchitis which is often unilateral is 
that due to the influenza bacillus. In the course of a case of influ- 
enza, a unilateral localized bronchitis not infrequently occurs. Over 
a patch of lung, perhaps the size of the palm of the hand, fine, moist 
rales may persist for weeks, finally clearing up only after the pa- 
tient has resumed his ordinary occupation. Doubtless such local- 
ized patches of bronchitis are often accompanied by foci of lobular 
pneumonia too small to be detected by our present methods of 
physical examination. 

Percussion dulness is absent in bronchitis except near the end 
of fatal cases, when the lung is stuffed with mucus and pus, or 
when atelectasis has occurred owing to extensive plugging of the 
larger bronchi. These events are rarely seen, and in general the 



294 PHYSICAL DIAGNOSIS. 

negative results of percussion are of great value in excluding sol- 
idification or fluid exudation. 

Occasionally percussion resonance may be increased owing to 
a slight temporary overdistention of the air vesicles from coughing. 1 

Inspection usually shows little or nothing of diagnostic impor- 
tance in acute bronchitis. Long-standing cases, complicated as 
they almost invariably are by emphysema, present changes in the 
shape of the thorax ; but these are due to the emphysema rather 
than to the bronchitis. In children acute bronchitis sometimes 
involves so many of the smaller bronchi that dyspnoea and use of 
accessory muscles of respiration are notable. But this usually 
means atelectasis, broncho-pneumonia, or laryngeal spasm, in addi- 
tion to the bronchitis. 

From violent coughhig the jugulars may be distended, but no 
systolic pulsation occurs in them. 

Voice sounds and tactile fremitus are normal. 

Differential Diagnosis . 

(Edema of the lung and bronchial asthma are the only pathologi- 
cal processes (except hemorrhage into the lung substance) which 
give rise to signs like those of bronchitis. 

(1) In osdema of the lung, or pulmonary apoplexy, one may 
find, as in simple bronchitis, a dimmished vesicular breathing with 
crackling rales, but cedema of the lung is almost always best marked 
in the dependent portions; that is, hi the posterior parts of the 
lung if the patient has been lying upon the back, or in the lower 
lobes if he has been sitting up. The rales of oedema are always 
moist, and are more uniform in size when compared to those of 
bronchitis. The recognition of a cause for the oedema, for ex- 
ample a non-compensated heart lesion, materially aids in the 
diagnosis. 

(2) Bronchial asthma or spasm of the finer bronchi produces dry 
squeaking and groaning sounds similar to those heard in the earlier 

1 In children examined during a crying-spell a cracked-pot sound can 
usually be elicited by percussion. This is in no way characteristic of bron- 
chitis and cap often be obtained in healthy infants. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 



295 



stages of many cases of bronchitis. But in bronchial asthma the 
rales are chiefly expiratory, and expiration is prolonged and inten- 
sified. Moreover, the inhalation of a few drops of amyl nitrite will 
temporarily dispel rales due to bronchial 
spasm, while on the rales of dry bronchitis 
it has no effect (Abrams). 

(3) Broncho-pneumonia. In many 
cases of lobular or broncho-pneumonia the 
physical signs are exclusively those of the 
coexisting bronchitis. In such cases the 
diagnosis of bronchitis is not wrong, but 
does not cover the whole ground. I shall 
discuss further under broncho-pneumonia 
the evidence which leads us to suspect 
that something more than bronchitis is 
present. 

(4) Muscle sounds. Under certain 
circumstances (cold, nervousness), the 
rumbling noises produced by muscular 
contractions in the chest wall may simu- 
late rales so closely that the diagnosis of 
bronchitis may be strongly suggested. 
The differentiation between rales and 
muscle sounds has already been discussed 
(see above, p. 146). 

(5) Atelectatic crepitation. Crackling 
rales heard over the thin margins of the 
lungs at the base of the axilla or along 
the edges of the manubrium are often due 

to atelectasis (see above). From bronchitis they are distinguished 
by their situation and by the lack of symptoms. They are best 
heard at the point shown in Fig. 158. 




Fig. 158. -The Dots are Placed 
over the Area where Atelecta- 
tic Crepitation is Oftenest 
Heard. 



Chronic Bronchitis. 

So far as the bronchitis itself is concerned, there may be no 
difference in the physical signs between the acute and chronic forms 



296 PHYSICAL DIAGNOSIS. 

of the disease ; but in the latter one almost invariably finds asso- 
ciated with the bronchitis itself a considerable degree of emphy- 
sema, of asthma, or of both conditions. Indeed, the foreground of 
the clinical picture and the bulk of the physical sign are made up 
by the emphysema and asthma, rather than by the bronchitis itself. 
Accordingly, I shall not discuss chronic bronchitis any further at 
this point, but will return to the subject in the chapter on Emphy- 
sema. 

CROUPOUS PNEUMONIA. 

In its typical form croupous or fibrinous pneumonia produces 
solidification of one or more lobes, usually the lower, the process 
being accurately bounded by the interlobular fissures. Although 
the physical signs of the earlier stages differ considerably from 
those of the later ones, there seems to be no sufficient ground for 
marking off stages of engorgement and of red and gray hepatiza- 
tion, for clinically these stages cannot be distinguished. 

The solidification may begin in the deeper parts of the lung 
(" central pneumonia"), so that no physical signs are obtainable 
unless, later in the course of the disease, the process extends to the 
surface of the lung. 

Massive pneumonia, in which the bronchi as well as the air cells 
are plugged with fibrin and leucocytes, is a relatively rare form of 
the disease, but possesses great clinical importance on account of the 
marked resemblance between its physical signs and those of pleural 
effusion. 

The frequency of endocarditis and pericarditis in connection 
with lobar pneumonia, especially with those of the left side, should 
be borne in mind. 

Physical Signs. 

(a) Inspection. — The aspect of the patient frequently suggests 

the diagnosis; the face is anxious, often flushed or slightly cya- 

nosed, the flush sometimes affecting most strikingly the side of the 

face corresponding to the lung affected. 1 Herpetic vesicles ("cold 

1 Perhaps because the patient is apt to lie upon the affected side. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 297 

sores ") are often to be seen aronnd the month or nose. The rapid, 
difficult breathing is at once noticable, and expiration is often ac- 
companied by a grnnt. The nse of the accessory muscles of respi- 
ration and the dilatation of the nostrils attract attention. 

The combination of marked dyspnoea with absence of dropsy is 
met with more frequently in pneumonia than in any other disease. 
Both sides of the chest usually move alike, but occasionally the 
affected side shows deficient expansion especially in the later stages 
of the disease, and the other side of the chest shows increased re- 
spiratory movements (compensatory). Rarely the pulsations of the 
heart may be transmitted to the chest wall through the affected lung. 

When pneumonia attacks a feeble old man, or follows injuries 
(surgical pneumonia), its onset may be insidious, and none of the 
phenomena just described may be seen. 

(b) Palpation. — In the great majority of cases tactile fremitus is 
markedly increased over the affected area, 1 but in case the bronchi 
are occluded by secretions or fibrinous exudate, fremitus may be di- 
minished or altogether absent. A few hard coughs will sometimes 
clear out the tubes and thus materially assist the diagnosis. Occa- 
sionally an increase in superficial temperature of the affected side 
may be noticed by palpation, and rarely one feels a friction rub 
due to the fibrinous pleurisy which almost invariably accompanies 
the disease. 

(c) Percussion. — Over the area affected the percussion note is gener- 
ally dull and may be almost flat, except in the earliest and latest 
stages of the disease, in which it may have a tympanitic quality with 
or without an element of slight dulness. More marked tympany is 
usually present over the unaffected lobes of the diseased lung (that 
is, over the upper lobes in the great majority of cases.) 

The conditions just described represent the great majority of 
cases, but the following exceptions occur : 

(1) In the pneumonias of children, and occasionally in adults, 
dulness may be absent. 

1 By using the edge instead of the flat of the hand the boundaries of sol- 
idified lobes may often be very accurately marked out by means of the tactile 
fremitus. 



298 PHYSICAL DIAGNOSIS. 

(2) When the lower lobe of the left lung is affected, a distinctly 
tympanitic quality may be transmitted to the consolidated area 
from a distended stomach or colon. 

(3) In rare cases, the percussion over the consolidated area may 
be of a metallic quality, or produce the " cracked-pot " sound. 

(4) In central pneumonia there may be no change in the percus- 
sion note, or it may be unusually full and deep so that the sound 
side seems dull by comparison. 

A solidified lobe increases so much in size that the area of dul- 
ness corresponding to it often seems incredibly large. Thus, al- 
though the lower lobe reaches in health not more than half-way up 
the scapula, when solidified it produces dulness throughout nearly 
the whole back. 

The right base is the most frequent seat of pneumonic soliclifica- 
tions, but the dulness corresponding to it is often first noticeable in 
the posterior axillary line. A dulness appreciable only in the front 
of the chest is almost sure to correspond to the upper lobe, while 
signs in the lower part of the right axilla correspond to the middle 
lobe. Many cases of central pneumonia first appear at the surface 
in one or the other axilla. 

As regards the amount of solidification needed to produce per- 
cussion dulness, Wintrich says that the minimum is a patch 5 cm. 
in diameter, 2 cm. deep, and superficially situated. 

Percussion often makes us aware of an increased resistance or 
diminished elasticity of the affected side, although the resistance is 
seldom as marked as in large pleural effusions. 

(d) Auscultation. — In the great majority of cases typical tubular 
breathing is to be heard over the affected area. Since a whisper 
is practically a forced expiration, this tubular quality is very well 
brought out if the patient is made to whisper "one, two, three," 
or any other succession of syllables, and by this method the fatigue 
and pain of deep breathing may be saved. By this use of the 
whispered voice one may accurately mark out the boundaries of the 
consolidated area, and demonstrate in many cases that it coincides 
with the boundaries of one lobe of the lung. 

In the earliest stages of the disease the breathing may be bron- 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 299 

cho- vesicular ; more often it is feeble or suppressed over the con- 
solidated area, and "crepitant rales," that is, very fine crackling 
sounds, may be heard at the end of inspiration, but these are much 
more common in the stage of resolution 1 ("crepitans redux "). 

If some of the smaller bronchi are blocked, as is not infre- 
quently the case, respiration is absent or very feeble, and such 
cases are often mistaken for pleuritic effusion. In pneumonia of 
the upper lobe it is not rare for bronchial breathing to be absent 
even without plugging of the bronchi. 

In cases of "central pneumonia," that is, when the area of 
solidification is in the interior of the organ, there may be no 
change in the breath sounds, or a bronchial element may be faintly 
audible on auscultation with the unaided ear, and only by this 
method. 

The intensity of the spoken or whispered voice is greatly in- 
creased over the area of consolidation, and sometimes the words 
can be distinguished. The nasal twang known as " egopliony " is 
occasionally to be heard. In the majority of cases, as has been 
already stated, the right lower lobe posteriorly is affected, so that 
the consolidated area is immediately in apposition with the spinal 
column. Under these circumstances, it is not r b all uncommon to 
hear bronchial breathing transmitted from the consolidated lobe 
to a narrow zone close along the spinal column on the sound side. 
Such a zone is often mistaken for consolidation (see Fig. 159). 

The signs are usually less marked in the axilla and in the front 
of the lung, but in a minority of cases, and especially when the 
upper lobes are affected, the signs are wholly in the front. When 
searching for evidences of consolidation in persons suspected to 
have pneumonia, one should never omit to examine the apices and 
very summit of the armpit, pressing the stethoscope up behind the 
anterior fold of the axilla. 

In examining the posterior lobes, when the patient is too weak 
to sit up and is loath even to turn upon the side, the Bowles steth- 

1 Crepitant rales are rarely heard in the pneumonias of infancy and Ola 
age. They are not peculiar to pneumonia, but occur in pulmonary oedema or 
hemorrhagic infarction— conditions easily distinguished from pneumonia. 



300 



PHYSICAL DIAGNOSIS. 



oscope is a great convenience, owing to the ease with which its flat- 
tened extremity may be worked in between the patient and the bed- 
clothes without causing any discomfort. 

When resolution begins, the signs may suddenly and completely 
disappear within a few hours. More frequently the bronchial 
breathing is modified to broncho- vesicular, dnlness and broncho- 
phony become less marked, fine crackling rales (crepitans re dux) 
or coarser moist bubbles appear, and the lung gradually returns to 
its normal condition within a period of three or four days. In the 



„^ Tympany. 



Bronchial breathing 
transmitted by 
spinal column to 
sound lung. 




Solidification. 



Fig. 159.— Diagram of Signs in Pneumonia. 



active stages of the disease the entire absence of rales is very char- 
acteristic. In about 19 per cent, of the cases the solidification of 
the lung persists after the fall of the temperature ; indeed, it may 
be weeks or even months before it clears up, and yet the lung may 
be perfectly sound in the end. On the other hand, abscess or gan- 
grene may develop in the solidified lobe, or the latter may be trans- 
formed into a mass of tough fibrous tissue, and the adjacent portion 
of the chest may fall in (cirrhosis of the lung, chronic interstitial 
pneumonia) . 

" Wandering pneumonia " is a term applied to cases in which 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 301 

the consolidation disappears in one lobe only to reappear in another, 
or spreads gradually from lobe to lobe. The physical signs In such 
cases do not differ essentially from those already described. 

Summary. 

In a typical case one finds (oftenest at the right base behind) 

1. Dulness on percussion. 

2. Increased tactile fremitus and voice sounds. 

3. Tubular breathing and occasionally crepitant rales. 

These signs occurring in connection with fever, cough, rusty 
sputa, pain in the side, dyspnoea, and herpes, are sufficient for the 
diagnosis. 

But many cases — some say the majority — are not typical when 
first seen. The following are the commonest anomalies : 

(a) There may be tympany instead of dulness, especially in 
children or when the solidification is at the left base. 

(&) The breathing may be feeble but vesicular in character, or 
it may be absent, in case bronchi are plugged ; from the same cause 

(c) Tactile fremitus may be diminished. 

A hard cough may clear out the bronchi and produce a sudden 
metamorphosis of the physical signs with a return to the normal 
type. 

In these atypical cases, we have to fall back upon the symp- 
toms, the history, the blood, and sputa for help in the diagnosis. 

Deep-seated pneumonic processes may appear at the surface in 
out-of-the-way places, e.g., at the summit of the axilla, and the 
area of demonstrable physical signs may be no larger than a silver 
dollar. A thorough examination of every inch of the chest is 
therefore essential in doubtful cases. 

In the later stages of the disease crepitant or other fine rales 
often appear, and the signs of solidification suddenly or gradually 
disappear. 

Differential Diagnosis. 

Pneumonic solidification is to be distinguished from 

(1) Pleuritic effusion. 

(2) Tuberculosis of the lung. 



302 PHYSICAL DIAGNOSIS. 

(1) From pleuritic effusion, pneumonia is to be distinguished 
in the' great majority of cases by differences in the onset, course, 
and general symptoms of the disease. In pneumonia the patient is 
far more suddenly and violently attacked, the dyspnoea is much 
greater, cough and pain are more distressing and more frequent, 
the temperature is higher, and the sputum often characteristic. In 
pleuritic effusion the dulness is usually more intense than hi pneu- 
monia. Tactile fremitus and voice sounds are increased hi pneu- 
monia (except when the bronchi are plugged) ; decreased or absent 
in pleuritic effusion. Bronchial breathing may be heard in both 
diseases, but is usually feeble and distant when occurring in pleu- 
risy, and loud in pneumonia. If the affection be on the left side, 
the diagnosis is much aided by the presence of dislocation of the 
heart, which is produced by pleuritic effusion and never by pneu- 
monia. In cases of pneumonia with occluded bronchi, one may 
have every sign of pleuritic effusion — flatness, absent breathing, 
voice and fremitus — and in such cases the absence of any disloca- 
tion of the heart, provided the disease is upon the left side, is very 
important. If a similar condition of things occurs upon the right 
side, one may have to fall back upon the symptoms and upon such 
evidence as the blood count, herpes, sputum, etc. 

(2) Tuberculosis of the lung caushig, as it may, a diffuse sol- 
idification of the organ, may be indistinguishable from pneumonia 
if we take account only of the physical signs, but the two diseases 
can usually be distinguished without difficulty by the difference in 
their symptoms and course, and by the presence or absence of tuber- 
cle bacilli in the sputum. 

Inhalation Pneumonia. Aspiration Pneumonia. 

When food or other foreign substances are drawn into the air 
passages, as may occur, for example, during recovery from ether 
narcosis, a form of broncho-pneumonia may be set up, in which the 
solidified patches are not infrequently large enough to be recognized 
by the ordinary methods of physical examination. 

The lesions are usually bilateral and accompanied by a general 
bronchitis. Slight dulness and indistinct bronchial breathing can 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 303 

usually be made out over an irregular area in the backs of both 
lungs. 

The signs are considerably less marked than in croupous pneu- 
monia, and the boundaries of the irregular patches of disease do 
not correspond to those of a lobe of the lung. 

If not rapidly fatal, the disease may be complicated by pulmo- 
nary gangrene or abscess and large quantities of fetid pus may be 
spit up. 

Broncho-Pneumonia. 
(Catarrhal or Lobular Pneumonia.) 

Multiple small areas of solidification scattered through both 
lungs, interspersed with areas of collapse, and usually associated 
with diffuse bronchitis, occur very frequently in children producing 
severe dyspnoea, cyanosis, cough, and somnolence, and running a 
very fatal course. 

The solidified lobules may fuse so as to form considerable areas 
of hepatized lung, or there may be no lesion larger than a pea. 

This is the usual type of " lung fever " in infants, although or- 
dinary lobar pneumonia is not rare in infancy and in childhood. 

The widespread atelectasis of the lower lobes which is associated 
with the disease hi most cases owing to the plugging of the bronchi 
with tenacious secretions, is probably as serious in its effects as the 
pneumonic foci themselves. 

The anterior and upper parts of the lungs often become dis- 
tended with air (vicarious emphysema) and render the physical 
signs very confusing and deceptive. 

Physical Signs. 

In the majority of cases there are no characteristic physical 
signs, and the diagnosis has to be made largely from the symptoms 
and course of the disease. The consolidated areas are usually too 
small to give rise to any dulness on percussion, or to any change in 
the breath sounds, voice sounds, or fremitus, so that auscultation 
shows, as a rule, nothing more than patches of fine rales occurring 
at the end of expiration. Localized tympanitic resonance is some- 



304 PHYSICAL DIAGNOSIS. 

times present over the diseased area, making the sounder portions 
of the lungs seem dull by comparison. Occasionally, when many 
lobules have fused into a single mass of larger area, the ordinary 
signs of consolidation may be obtained, although they are apt to 
disappear within twenty-four or forty-eight hours and appear in 
another situation. As above said, the diagnosis is usually to be 
made, if at all, from the combination of the physical signs of a 
localized bronchitis with the symptoms of pneumonia. " This pa- 
tient," we say, "has only the signs of bronchitis, but he is too 
sick. The cyanosis, dyspnoea, and fever are too marked. He is 
sicker than simple bronchitis will account for." 

Differential Diagnosis. 

(a) Acute pulmonary tuberculosis may be indistinguishable from 
broncho-pneumonia by the physical signs alone. The diagnosis 
must be made from the history and course of the disease or from 
the presence of tubercle bacilli in the sputa. 

(b) The extensive atelectasis of the lower lobes which may ac- 
company broncho-pneumonia gives rise to dulness and absence of 
respiratory and vocal sounds. Thus, the signs of pleuritic effusion 
are simulated, and in children the possibility of empyema should 
not be forgotten. As a rule, broncho-pneumonia gives rise to much 
greater dyspnoea, and is associated with a more extensive bronchitis, 
than usually coexist with pleural effusion. The atelectatic lobules 
may be expanded by coughing or by the cutaneous stimulus of cold 
water, and thus resonance and breath sounds may suddenly return. 
With pleuritic effusions, of course, such a change is impossible. 

TUBEKCULOSIS OF THE LUNGS. 

(1) Incipient Tuberculosis. 

In the earlier stages of the disease there may be absolutely no 
recognizable physical signs, and the diagnosis may be established 
only by the positive result of a tuberculin injection or by the com- 
bination of debility with slight fever not otherwise to be accounted 
for. 






BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 



305 



In some cases the earliest evidence of the disease is haemoptysis.' 
When a patient consults a physician on account of haemoptysis, it 
is frequently impossible to find any physical signs of disease in the 
lungs ; not until weeks or months later do the characteristic changes 
recognizable by physical examination make their appearance. 

The very early hoarseness of the voice in tuberculous patients is 
of great importance and often attracts our attention to the lungs 
when the patient has said nothing about them. Definite physical 
signs in the lungs and tubercle bacilli in the sputa (artificially ob- 



Rales. 




Fig. 160.- Diagram to Show Position of Earliest Signs in Tuberculosis. 



tained through the use of potassic iodide, see below) may occasion- 
ally be demonstrated before any cough has appeared. On the other 
hand, the patient may cough for weeks before anything abnormal 
can be discovered in the lungs. Occasionally tuberculosis begins 
with an ordinarily bilateral bronchitis. I have found tubercle ba- 
cilli in four such cases. More often the earliest physical signs 
are: 

(a) Fine crackling rales at the apex of one lung, heard only 

1 Never percuss a patient within forty-eight hours after a hemorrhage, and 
never encourage cough or forced respiration in such a one. There is danger 
of starting a fresh hemorrhage. 

20 



306 PHYSICAL DIAGNOSIS. 

with or after cough and at the end of inspiration. [More rarely 
squeaks may be heard.] (See Fig. 160). 

(b) A slight diminution in the excursion of the diaphragm on 
the affected side, as shown by Litten's diaphragm shadow. 

(c) Slight diminution in the intensity of the respiratory mur- 
mur, with or without interrupted inspiration (" '' cog-ivheel breath- 
ing"). 

(a) In examining the apices of the lungs for evidence of early 
tuberculosis one should secure if possible perfect quiet in the room, 
and have the clothes entirely removed from the patient's chest. 
The ordinary hard-rubber chest-piece is better than the chest-piece 
of the Bowles instrument when we wish to search the apices for 
fine rales. After listening during quiet breathing over the apices 
above and below the clavicle in front, and above the spine of 
the scapula behind, the patient should be directed to breathe out 
and then, at the end of expiration, to cough. During the deep 
inspiration which is likely to precede or to follow such a cough one 
should listen as carefully as possible at the apex of the lung, above 
and below the clavicle, concentrating attention especially upon the 
last quarter of the inspiration, when rales are most apt to appear. 
Sometimes only one or two crackles may be heard with each inspi- 
ration, and not infrequently they will not be heard at all unless the 
patient is made to cough, but even a single rale, if persistent / is 
important. In children who cannot cough at will, one can accom- 
plish nearly the same result by making them count as long as pos- 
sible with one breath and then listening to the immediately suc- 
ceeding inspiration. When listening over the apex of the lung, 
one should never allow the patient to turn his head sharply in the 
other direction, since such an attitude stretches the skin and mus- 
cles on the side on which we are listening so as to produce annoy- 
ing muscle sounds or skin rubs. 

In cases in which one suspects that incipient tuberculosis is 

1 Rales heard only during the first few breaths and not found to persist on 
subsequent examinations, may be due to the expansion of atelectatic lobules. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 307 

present and yet in which no positive evidence can be found, it is a 
good plan to give iodide of potassium (gr. vii. three times a day) for 
a few days. The effect of this drag is often to make rales more 
distinct, and sometimes to increase expectoration so that tubercle 
bacilli can be demonstrated when before none were to be obtained. ' 

(b) The diminution in the excursion of the diaphragm upon the 
affected side in cases of incipient phthisis has been much insisted 
upon by F. H. Williams and others who have interested themselves 
in the radioscopy of the chest. Litten's diaphragm shadow gives 
us a method of observing the same phenomenon without the need 
of a fluoroscope. Even very slight tuberculous changes in the lung 
are sufficient to diminish its elasticity and so to restrict its excur- 
sion and that of the diaphragm. Comparisons must always be 
made with the sound side in such cases, as individuals differ very 
much in the extent with which they are capable of depressing the 
diaphragm. It must be remembered that pleuritic adhesions, due 
to a previous inflammation of the pleura, may diminish or alto- 
gether abolish the excursion of the diaphragm shadow, independ- 
ently of any active disease in the lung itself. 

Those who are expert in the use of the fluoroscope believe that 
they can detect the presence of tuberculosis in the lung by radi- 
oscopy at a period at which no other method of physical examina- 
tion shoAvs anything abnormal. I shall return to the consideration 
of this point in the section on Radioscopy. 2 

Interrupted or cog-wheel respiration, in which the inspiration 
is made up of sharp, jerky puffs, signifies that the entrance of the 
air into the alveoli is impeded, and such impediment is most likely 
to be due to tuberculosis when present over a considerable period 
in a localized area of pulmonary tissue. 

1 Any irritating vapor — for example, creosote vapor — which produces vio- 
lent cough and expectoration, may be used to expel bronchial secretions in 
doubtful cases. Tubercle bacilli may then be found in the sputum of patients 
who, without the irritating inhalation, have no cough and so no sputa. 

2 See Appendix C. 



308 



PHYSICAL DIAGNOSIS. 



(2) Moderately Advanced Cases 

So far I have been speaking of the detection of tuberculosis at 
a stage prior to the production of any considerable amount of solid- 
ification. The signs considered have been those of bronchitis 
localized at the apex of the lung, or of a slightly diminished pul- 
monary elasticity, whether due to pleuritic adhesions or to other 
causes. We have next to consider the signs in cases in which so- 
lidification is present, though relatively slight in amount, This 
condition is comparatively easy to recognize when it occurs at the 



Rales.- 




^ Complete 
solidification. 



Partial 
solidification. 



_-4 — Rales. 



Fig. 161.— Diagram of Signs in Phthisis. 



left apex, but more difficult in case only the right apex is diseased 
Partial solidification of a small area of lung tissue at the left apex 
gives rise to 

(a) Slight dulness on light percussion, 1 with increased resist- 
ance. 

(b) Slight increase in the intensity of the spoken and whispered 
voice, and of the tactile fremitus (in many cases) 

1 Other causes of dulness, such as asymmetry of the chest, pleural thicken- 
ing, and tumors, must be excluded. Emphysema of the lobules surrounding 
the tuberculous patch may completely mask the dulness. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 309 

(c) Some one of the numerous varieties of broncho-vesicular 
breathing (true bronchial breathing is a late sign). 

(d) Abnormally loud transmission of the heart sounds, espe- 
cially under the clavicle. 

(e) Cardio-respiratory murmurs (vide p. 197^ are occasionally 
due to the pressure of a tuberculous lobule upon the subclavian 
artery. In connection with other signs they are not altogether 
valueless in diagnosis 

In case there is also a certain amount of secretion in the bron- 
chi of the affected area or ulceration around them, one often hears 
rales of a peculiar quality to which Skoda has given the name of 
" consonating rales." Rales produced in or very near a solidified 
area are apt to have a very sharp, crackling quality, their intensity 
being increased by the same acoustical conditions which increase 
the intensity of the voice sounds over the same area. When such 
rales are present at the apex of either lung, the diagnosis of tuber- 
culosis is almost certain, but if, as not infrequently occurs, there 
are no rales to be heard over the suspected area, our diagnosis is 
clear only in case the signs occur at the left apex. Precisely the 
same signs, if present at the right apex, leave us in doubt regard- 
ing the diagnosis, for the reason that, as has been explained above, 
we find at the apex of the right lung in health signs almost exactly 
identical with those of a slight degree of solidification. Hence, if 
these signs, and only these, are discovered at the right apex, we 
cannot feel sure about the diagnosis until it is confirmed by the 
appearance of rales in the same area of the left side (whether under 
the influence of iodide of potassium or spontaneously), or by the find- 
ing of tubercle bacilli in the sputum. 1 

A sign characteristic of early tuberculous changes in the lung and 
one which I have frequently observed in the lower and relatively 
sounder lobes of tuberculous lungs is a raising of the pitch of inspi- 
ration, without any other change in the quality of the breathing or 
any other physical signs The importance of this sign in the diag- 

1 The natural disparity between the two apices is less marked in the supra- 
spinous fossa behind than over the clavicle in front, and hence pathological 
duiness at the apex is more often demonstrable behind than in front. 



310 



PHYSICAL DIAGNOSIS. 



nosis of early tuberculosis of the lungs was insisted upon by the 
eider Flint in his work on "The Respiratory Organs" (1866), and 
has more recently been mentioned by Norman Bridge. 

It must never be forgotten that tuberculosis may take root in 




fig. 162. 



-This Patient has Solidification at both Apices and Tubercle Bacilli in the Sputa, 
feels perfectly well. 



He 



the most finely formed chests and in persons apparently in blooming 
health. The "phthisical chest " and the sallow, emaciated figure of 
the classical descriptions apply only to very advanced cases. Fig. 
162 represents a patient with moderately advanced signs of phthisis 
and abundant tubercle bacilli in the sputa. He feels perfectly 



^ 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 311 

well and is at work. On the other hand, a patient with very slight 
signs may be utterly prostrated by the toxaemia of the disease. 

(3) Advanced Phthisis. 

Characteristic of the more advanced stages of tuberculosis in the 
lungs is the existence of large areas of solidified and retracted lung, 
and, to a lesser extent, the signs of cavity formation. The patients 
are pale, emaciated, and feverish. The signs of solidification have 
already been enumerated in speaking of pneumonia. They are : 

1. Marked dulness, or even flatness, 1 with increased sense of re- 
sistance. 

2. Great increase of voice sounds or of tactile fremitus. 

3. Tubular breathing, sometimes loud, sometimes feeble. 

4. As a rule, coarse rales, due to breaking down of the caseous 
tissue, are also to be heard over the solidified areas. Sometimes 
these rales are produced within the pleuritic adhesions, which are 
almost invariably present in such cases. If they disappear just 
after profuse expectoration, one may infer that they are produced 
within the lung. 

Increase in the intensity of the spoken voice, of the whispered 
voice, or of the tactile fremitus may be marked and yet no tubular 
breathing be audible. Each of these signs may exist and be of im- 
portance as signs of solidification without the others. As a rule, 
it is true, they are associated and form a very characteristic group, 
but there are many exceptions to this rule. 

The tendency of the spinal column to transmit to the sound 
lung sounds produced in an area of solidification immediately 
adjacent to it on the other side, has been already alluded to in 
the section on pneumonia, and what was then said holds good of tu- 
berculous solidification. Owing to this it is easy to be misled into 
diagnosing solidification at both apices when only one is affected. 

Since solidification is usually accompanied by retraction in the 
affected lung in very advanced cases, the chest falls in to a greater 

1 Unless senile emphysema masks it. Fibroid phthisis (vide infra) may- 
show no dulness. Remember that gastric tympany may be transmitted to the 
left lung and mask dulness there. 



312 



PHYSICAL DIAGNOSIS. 



or less extent over the affected area, and the respiratory excursion 
is much diminished, as shown by ordinary inspection and by the 
diminution or disappearance of the excursion of the diaphragm 
shadow. The intensity of the tubular breathing depends on the 
proximity of the solidified portions to the chest wall and to the 
large bronchi, as well as on the presence or absence of pleuritic 
thickening. 

It is rare to find a whole lung solidified. The process, begin- 
ning at the apex or just below, extends down as far as the fourth 



Bronchiiil breath- 
ing, dulness. 



Increased fremitus. 



Increased voice 
sounds. 



,- Rales. 



Rales. 




Fig. 163.— To Illustrate Progress of Signs in Pulmonary Tuberculosis. 



rib in front, i.e., through the upper lobe, in a relatively short time, 
but below that point its progress is comparatively slow and the 
lower lobes may be but little affected up to the time of death. On 
the relatively sound side the exaggerated (compensatory) resonance 
may mask the dulness of a beginning solidification there, which 
sooner or later is almost sure to occur. It is exceedingly rare for 
the disease to extend far in one lung without involving the other. 

About the time that the tuberculous process invades the previ- 
ously sound lung it is apt to show itself at the apex of the lower lobe 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 313 

of the lung first affected. Consonating rales appear posteriorly along 
the line which the vertebral border of the scapula makes when the 
arm is raised over the shoulder. These points are illustrated in 
Fig. 163. 

Cavity Formation. 

Cavities of greater or lesser extent are formed in almost every 
case of advanced phthisis, but very seldom do they attain such size 
as to be recognizable during life. Indeed, the diagnosis of cavity 
in phthisis plays a much larger part in the text-books than it does 
in the practice of medicine, since to be recognizable by physical 
examination a cavity must not only be of considerable size but its 
walls must be rigid and not subject to collapse, 1 it must communi- 
cate directly with the bronchus and be situated near the surface of 
the lung, and it must not be filled up with secretions. It can read- 
ily be appreciated that it is but seldom that all these conditions are 
present at once ; even then the diagnosis of cavity is a difficult one, 
and I have often known skilled observers to be mistaken on this 
point. 

The signs upon which most reliance is usually placed are : 

(a) Amphoric or cavernous breathing. 

(b) " Cracked-pot resonance " on percussion. 

(c) Coarse, gurgling rales. 

(a) Cavernous or Amphoric Respiration. — When present, this 
type of breathing is almost pathognomonic of a cavity. It is also 
to be heard in pneumothorax, but the latter disease can usually 
be distinguished by the associated physical signs. Cavernous 
breathing differs from bronchial or tubular breathing in that its 
pitch is lower and its quality hollow. The pitch of expiration 
is even lower than that of inspiration. Since a pulmonary cavity 
is almost always surrounded by a layer of solidified lung tissue, we 
usually hear around the area occupied by the cavity a ring of bron- 
chial breathing with which we can compare the quality of the cav- 
ernous sounds. 

1 Yet not so rigid as to be uninfluenced by the entrance and exit of air. 



314 PHYSICAL DIAGNOSIS. 

(b) Percussion sometimes enables us to demonstrate a circum- 
scribed area of tympanitic resonance surrounded by marked dul- 
ness. More often the "cracked-pot" resonance can be elicited by 
percussing over the suspected area while the chest-piece of the 
stethoscope is held close to the patient's open mouth. 

Cracked-pot resonance is often absent over cavities ; rarely oc- 
curs in any other condition (e.g., in percussing the chest of a 
healthy, crying baby, and occasionally over solidified lung). 

(c) The voice sounds sometimes have a peculiar hollow quality 
(amphoric voice and whisper). 

(d) Cough or the movements of respiration may bring out over 
the suspected area splashing or gurgling sounds, or occasionally 
a metallic tinkle. Flint has also observed a circumscribed bulging 
of an interspace during cough. Bruce noted a high-pitched suck- 
ing sound during the inspiration following a hard cough (''rubber- 
ball sound"). 

Very important in the diagnosis of cavity is the intermittence of 
all above-mentioned signs, which are present only when the cavity 
is comparatively empty, and disappear when it becomes wholly or 
mostly filled with secretions. For this reason, the signs ar© very 
apt to be absent in the early morning before the patient has expelled 
the accumulated secretions by coughing. 

Wintrich noticed that the note obtained when percussing over 
a pulmonary cavity may change its pitch if the patient opens his 
mouth. Cerhardt observed that the note obtained over a pulmo- 
nary cavity changes if the patient shifts from an upright to a re- 
cumbent position, Neither of these points, however, is of much 
importance in diagnosis. The same is true of metamorphosing 
breathing (see above, p. 156). 

Tuberculous cavities differ from those produced by pulmonary 
abscess or gangrene in that the latter are usually situated in the 
lower two-thirds of the lung. Bronchiectasis, an exceedingly rare 
condition, cannot be distinguished by physical signs alone from a 
tuberculous cavity. 



BRONCHITIS, PNEUMONIA, TUBERCULOSIS. 315 

Fibroid Phthisis. 

This term applies to slow tuberculous processes with relatively 
little ulceration and much fibrous thickening. 

In a considerable number of cases the physical signs do not 
differ materially from those of the ordinary ulcerating forms of 
the disease, but occasionally when a slow chronic process at the 
apex of the lung results in the falling-away of the parenchyma of 
the lung so that we have left a cluster of bronchi matted together 
by fibrous tissue, the percussion note may be noticeably tympani- 
tic; similar tympany may be due to emphysema of the lobules 
surrounding the diseased portion. In such cases rales are usu- 
ally entirely absent ; otherwise, the signs do not differ from those 
of ordinary phthisis, except that falling-in of the chest walls over 
the retracted lung may be more marked. Occasionally the heart 
maybe drawn toward the affected lobes, e.g., upward and to the 
right in right-sided phthisis at the apex. In two cases of fibroid 
disease at the left base, Flint found the heart beating near the 
lower angle of the left scapula. 

Phthisis with Predominant Pleural Thickening. 

Tuberculosis in the lung is in certain cases overshadowed by the 
manifestations of the same disease in the pleura, so that the signs 
are chiefly those of thickened pleura. To this subject I shall return 
in the section of Diseases on the Pleura (see below, p. 331). 

Emphysematous Form of Phthisis. 

Tubercle bacilli are not very infrequently found in the sputa of 
cases in which the history and physical signs point to chronic bron- 
chitis with emphysema. I have seen two such cases within a year 
Durness is wholly masked by emphysema, tubular breathing is 
absent, and piping and babbling rales are scattered throughout both 
lungs. The emphysema may be of the senile or small-lunged type, 
as in one of my recent cases (with autopsy), or it may be associ- 
ated with huge downy lungs and the "barrel chest." Such cases 



316 PHYSICAL DIAGNOSIS. 

cannot be identified as phthisis during life unless we make it an 
invariable rule to examine for tubercle bacilli the sputa of every 
case in which sputa can be obtained, no matter ivhat are the physi- 
cal signs. 

Phthisis with Anomalous Distribution of the Lesions. 

Very rarely a tuberculous process may begin at the base of the 
lung "When the process seems to begin in this way, a healed focus 
is often to be found at one apex surrounded by a shell of healthy 
lung. 

The summit of the axilla should always be carefully examined, 
as tuberculous foci may be so situated as to produce signs only at 
that point. 

Another point often overlooked in physical examination is the 
lingula pulmonalis or tongue-like projection from the anterior mar- 
gin of the left lung overlapping the heart. Tuberculosis is some- 
times found further advanced at this point than anywhere else. 

As a rule cases in which signs like those of phthisis are found 
at the base of the lung turn out to be either empyema, or abscess, 
or unresolved pneumonia (cirrhosis of the lung). 

Acute Pulmonary Tuberculosis. 

No one of the three forms in which acute phthisis occurs, viz., 

(a) Acute tuberculous pneumonia, 

(b) Acute tuberculous bronchitis and peribronchitis, 

(c) Acute miliary tuberculosis, involving the lungs, can be rec- 
ognized by physical examination of the chest. The first form is 
almost invariably mistaken for ordinary croupous pneumonia, until 
the examination of the sputa establishes the correct diagnosis. In 
the other two forms of the disease, the physical signs are simpiy 
those of general bronchitis. 



CHAPTER XV. 

EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 

I. Emphysema. 

For clinical purposes, the great majority of cases of emphy- 
sema may be divided into two groups. 

(1) Large-lunged emphysema, usually associated with chronic 
bronchitis and asthma. 

(2) Small-lunged, or senile, emphysema. 

Although the second of these forms is exceedingly common, it 
is so much less likely than the first form to give rise to distressing 
symptoms that it is chiefly the large-lunged emphysema which is 
seen by the physician. In both conditions we have a dilatation 
and finally a breaking down of the alveolar walls until the air spaces 
are become relatively large and inelastic. In both forms, the elas- 
ticity of the lung is diminished ; but in the large-lunged form we 
have an increase in the volume of the whole organ in addition to 
the changes just mentioned. 

Large-Lunged Emphysema. 

The diagnosis can usually be made by inspection alone. In 
typical cases the antero-posterior diameter of the chest is greatly 
increased, the in-spaces are widened, and the costal angle is blunted, 
while the angle of Luclwig 1 becomes prominent. The shoulders are 
high and stooping and the neck is short (see Fig. 164). The patient 
is often considerably cyanosed, and his breathing rapid and difficult. 
Inspiration is short and harsh ; expiration prolonged and difficult. 
The ribs move but little, and, owing to the ossification of their car- 

1 Formed by the junction of the manubrium with the second piece of the 
sternum. 



318 



PHYSICAL DIAGNOSIS. 



tilages, are apt to rise and fall as if made in one piece (en cui- 
rasse). The working of the auxiliary muscles of respiration is not 
infrequently seen. The diaphragm shadow (Litten's sign) begins 
its excursion one or two ribs farther down than usual and moves a 
much shorter distance than in normal cases. 

Paljmtion shows a diminution in the tactile fremitus, through- 
out the affected portions ; that is, usually throughout the whole of 
both lungs. Sometimes it is 
scarcely to be perceived at all. 

Permission yields very in- 
teresting information. The 
disease manifests itself— 

(a) By hyper-resonance on 
percussion, with a shade of 
tympanitic quality in the note. 

(b) By the extension of the 
margins of the lung so that 
they encroach upon portions of 
the chest not ordinarily reso- 
nant. 

The degree of hyper-reso- 
nance depends not only upon 
the degree of emphysema but 
upon the thickness of the chest 

walls. The note is most resonant and has most of the tympanitic 
quality when the disease occurs in old persons with relatively thin 
chest Avails. The encroachment of the over-voluminous lungs upon 
the liver and heart is demonstrated by the lowering of the line of 
liver flatness from its ordinary position at the sixth rib to a point 
one or two interspaces farther down or even to the costal margin, 
while the area of cardiac dulness may be altogether obliterated, 
the lungs completely closing over the surface of the heart. At the 
apices of the lungs resonance may be obtained one or two centi- 
metres higher than normally and the quality may be markedly tym- 
panitic. In the axillae and in the back the pulmonary resonance 
extends down one inch or more below its normal position. 




Fig. 164.-Barrel Chest due to Chronic Bion- 
chitis and Emphysema. 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 319 

Auscultation shows in uncomplicated cases no very marked, mod- 
ification of the inspiratory murmur, which, however, may be short- 
ened and enfeebled. The most striking change is a great prolonga- 
tion and enfeeblement of expiration, with a lowering of its pitch 
(see Fig. 165). 

This type of breathing is like bronchial breathing in one re- 
spect; namely, that in both of them expiration is made prolonged, 
but emphysematous breathing is feeble and low- 
pitched, while bronchial breathing is intense 
and high-pitched. At the bases of the lungs 
the respiration is especially feeble and may be 
altogether replaced by crackling rales. 

In " small-lunged emphysema " we have 
precisely the same physical signs, except that 

Fig. 165.— Diaeram to ,, -, -. « ., , , n 1 

illustrate Emphyse- the boundaries of the lung are not extended, 
matous Breathing expiration is less prolonged and less difficult, 

with Musical Expira- ...... , _. , , 

tory Rales. an d inspiration is normal. It does not tend 

to be complicated by bronchitis and asthma: 
indeed the small-lunged emphysema rarely gives rise to any symp- 
toms, and is discovered as a matter of routine physical examination. 

Summary. 

1. Hyper-resonance on percussion. 

2. Feeble breathing with prolonged expiration. 

3. Diminished fremitus and voice sounds. 

4. Encroachment of the resonant lungs on the heart and liver 
dulness (in the large-lunged form). 

Differential Diagnosis. 

(a) Emphysema may be confounded with pneumothorax, since in 
both conditions hyper-resonance and feeble breathing are present. 
But emphysema is usually bilateral, encroaches upon but does not 
displace neighboring organs, and is not often associated with hydro- 
thorax. Emphysema, if extensive, is usually associated with 
chronic bronchitis and so with squeaking or bubbling' rales, while in 



320 PHYSICAL DIAGNOSIS. 

pneumothorax breathing is absent or distant amphoric without 
rales. 

(b) The signs of aneurism of the aorta pressing on the trachea 
or on a primary bronchus are sometimes overlooked because the fore- 
ground of the clinical picture is occupied by the signs of a coexist- 
ing bronchitis with emphysema. The cough and wheezing which 
the presence of the aneurism produces may then be accounted for 
as part of the long-standing bronchitis, and the dulness and thrill 
over the upper sternum to which the aneurism naturally gives rise 
may be masked by extension of lung borders. But the evidence of 
pressure on mediastinal nerves and vessels (aphonia, unequal pulses 
or pupils, etc.), and the presence of a diastolic shock and tracheal 
tug are usually demonstrable ; the danger is that we shall forget to 
look for them. 

(c) Uncompensated mitral stenosis may produce dyspnoea and 
cyanosis and weak rapid heart action somewhat similar to that seen 
in emphysema, and may not be associated with any cardiac mur- 
mur, but the dyspnoea is not of the expiratory type, and the irregu- 
larity of the heart, with evidence of dropsy and general venous 
stasis, should make it evident that something more than simple em- 
physema is present. 

(d) The occurrence of an emphysematous form of phthisis I 
have already mentioned in discussing the latter disease (see p. 304). 

Emphysema with Bronchitis or Asthma. 

In the great majority of cases, emphysema of the lungs is asso- 
ciated with chronic bronchitis and very often with asthmatic parox- 
ysms. Such association is especially frequent in elderly men who 
have had a winter cough for many years and in whom arterio-scle- 
rosis is more or less well marked. In such cases the prolonged and 
feeble expiration is usually accompanied by squeaking and groaning 
sounds, or by moist rales of various sizes and in various parts of 
the chest. When the asthmatic element predominates, dry rales 
are more noticeable, and occur chiefly or wholly during expiration, 
while inspiration is reduced to a short, quick gasp. 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 321 

Interstitial Emphysema . 

In rare cases violent paroxysms of coughing may rupture the 
walls of the alveoli so as to allow the passage of air into the inter- 
stitial tissue of the lung, from whence it may work through and 
manifest itself under the skin, giving rise to a peculiar crackling 
sensation on palpation, and to a similar sound on auscultation. 
More frequently the trouble arises in connection with a tracheot- 
omy wound, the air penetrating under the skin and producing a 
downy, crepitating swelling. 

" Complementary Emphysema." 

When extra work is thrown upon one lung by loss of the func- 
tion of the other, as in pleuritic effusion — a considerable stretching 
of the overworked sound lung may take place. The elasticity of 
the lung is not diminished as in emphysema, but is greatly in- 
creased. Hence the term complementary emphysema should be 
dropped and the term complementary (or compensatory) hyper- 
resonance substituted. 

Like emphysema, this condition leads to hyper-resonance on per- 
cussion and to encroachment of the pulmonary margins upon the 
neighboring organs (as shown by a reduction in the area of dulness 
corresponding to them), but the respiratory murmur is exaggerated 
and has none of the characteristics of emphysematous breathing. 

A word may here be added regarding the condition described 
by West under the name of 

Acute Pulmonary Tympanites. 

In fevers and other acute debilitating conditions West has ob- 
served that the lungs may become hyper-resonant and somewhat 
tympanitic on percussion, owing, he believes, to a loss of pulmo- 
nary elasticity. The tympanitic note, often observable around the 
solidified tissue in pneumonia, is to be accounted for, he believes, 
in the same way. Like the shortening of the first heart sound, 
acute pulmonary tympanites points to the weakening of muscle fibre 
which toxaemia is so apt to produce. Apparently the muscle fibres 
of the lung suffer like those of the heart. 
21 



322 PHYSICAL DIAGNOSIS. 

BKONCHIAL ASTHMA. 

(Primary Spasm of the Bronchi). 

During a paroxysm of bronchial asthma our attention is at- 
tracted even at a distance by the loud, wheezing, prolonged expira- 
tion preceded by an abortive gasping inspiration. The breathing 
is labored, much quickened in rate, and cyanosis is very marked. 
The chest is distended and hyper-resonant, the position of the dia- 
phragm low and its excursion much limited, and the cardiac and 
hepatic dulness obliterated by the resonance of the distended lungs. 
On auscultation, practically no respiratory murmur is to be heard 
despite the violent plunging of the chest walls. We hear squeaks, 
groans, muscular rumbles, and a variety of strange sounds, but 
amid them all practically nothing is to be heard of the breath 
sounds. " The asthmatic storm flits about the chest, now here now 
there," the rales appearing and disappearing. 

At the extreme base of the lungs there may be dulness due to 
atelectasis of the thin pulmonary margins. 

Differential Diagnosis. 

(a) Mechanical irritation of the bronchi, as by the pressure of 
an aneurism or enlarged gland, may set up a spasm of the neigh- 
boring bronchioles much resembling that of primary bronchial 
asthma, but thorough examination should reveal other evidence 
of mediastinal pressure, and the history of the case is very different 
from that of asthma. 

(b) Spasm of the glottis produces a noisy dyspnoea, but the diffi- 
culty is with inspiration, instead of with expiration, and the crow- 
ing or barking sound is not like the long wheeze of asthma. No 
rales are to be heard, and the signs in the lungs are those of col- 
lapse instead of the distention characteristic of asthma. 

(c) The paroxysmal attacks of dyspnoea, which often occur in 
chronic nephritis, myocarditis, and other diseases of the heart and 
kidney, may be entirely indistinguishable from primary bronchial 
asthma but for the evidence of the underlying cardiac or renal dis- 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 6%i 

ease. As a rule, however, the element of spasm is much less 
marked ; the breathing is quick and labored but not wheezing, expi- 
ration is less prolonged, and the squeaking and groaning rales of 
asthma are not present. 

SYPHILIS OF THE LUNG. 

The diagnosis cannot be made with certainty from the physical 
signs, and rests entirely (in the rare cases in which it is made at all) 
on the history, the evidence of syphilis elsewhere in the body, and 
the result of treatment. Most cases are mistaken for phthisis. 

Any case supposed to be phthisis, but in which the examination 
of the sputa for tubercle bacilli is repeatedly negative, should be 
given a course of syphilitic treatment. 

The physical signs, as in phthisis, are those of localized bron- 
chitis or of solidification, but the lesions are not at the apex but 
usually about the root of the lung or lower down. Cavities are not 
formed. Stenosis of a bronchus may occur with resulting atelecta- 
sis of the corresponding lobules. 

Bronchiectasis (Bronchial Dilatation). 

This rare disease is still more rarely to be recognized during 
life. It is suggested by the history of raising within a few seconds 
or minutes a large amount of foul sputa, a pint or more in marked 
cases. The physical signs may not be in any way distinctive, or 
may be those of pulmonary cavity due to tuberculosis. Prom the 
latter bronchiectasis is to be distinguished in some cases by a 
knowledge of the previous history. Signs of cavity in phthisis are 
preceded and surrounded by signs of solidification in the same area, 
while in bronchiectasis this is not the case. Again, a bronchiecta- 
tic cavity is apt to occur, not at the apex, as in phthisis, but in the 
middle and lower thirds of the lung posteriorly. Aside from the 
history and situation of the cavity and the presence or absence of 
solidification around it, we cannot tell from physical signs whether 
it be due to tuberculosis or to dilatation of a bronchus. In either 
case we have the signs discussed on page 313 (cracked-pot reso- 



324 PHYSICAL DIAGNOSIS. 

nance, amphoric breathing and voice sounds, coarse gurgling or 
splashing sounds on cough) — all these signs disappearing when the 
cavity becomes tilled with secretions. 

The disease may cause marked retraction of the chest on the 
affected side, and neighboring organs may be drawn out of place. 

Cirrhosis of the Lung. 
(Chronic Interstitial Pneumonia.) 

As an end stage of unresolved croupous pneumonia, or as a 
result of chronic irritation from mineral or vegetable dust, a shrink- 
age of a part or the whole of the lung may occur, which progresses 
until the pulmonary tissue is transformed into a fibrous mass en- 
closing bronchi. 

The side of the chest corresponding to the affected lung becomes 
shrunken and concave ; fremitus is increased, percussion resonance 
diminished or lost, respiration tubular with coarse rales. 

From tuberculosis the condition is to be distinguished solely by 
the history, the absence of bacilli in the sputa, and the comparative 
mildness of the constitutional symptoms. 

The right ventricle of the heart may become hypertrophied and 
later dilated with resulting tricuspid insufficiency. 

EXAMINATION OF SPUTA. 

I. Origin. — Probably the majority of all sputa, excepting to- 
bacco juice, come from the nasopharynx, and are hawked, not 
coughed up. It is rarely of value to examine such sputa, although 
influenza bacilli, diphtheria bacilli, pneumococci, and other bacteria 
may be found. 

What we want in most cases is sputa coughed up from the pri- 
mary bronchi or lower down, and the patient should be accordingly 
instructed. Early morning cough is most likely to bring up sputa 
from the bronchi. 

Young children do not raise sputum, but when it is important 
to obtain it we may insert the forefinger (covered with a bit of cot- 
ton) into the pharynx, so as to excite a spasm of coughing. The 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 325 

sputum is deposited on the cotton before the child has time to swal- 
low it, and may then be withdrawn and examined. 

II. Quantity. — If the amount expectorated is large (i.e., one- 
half a pint or more in twenty-four hours), we may be dealing with: 

1. Pulmonary oedema (watery, sometimes pink and frothy). 

2. Advanced phthisis (muco-purulent). 

3. Empyema ruptured into a bronchus (pure pus). 

4. Abscess of the lung (foul smelling). 

5. Bronchiectasis (large amount within a few minutes on change 
of position). 

III. Odor. — Unless retained in a lung cavity (abscess, bronchi- 
ectasis), sputum is rarely ill-smelling. In gangrene of the lung 
the breath as well as the sputum is horribly offensive, and the odor 
soon fills the room and the house. 

IV. Gross Appearances. — (a) Bloody sputum (haemoptysis) 
means pure or nearly pure blood in considerable quantity, a tea- 
spoonful or more, not mere streaks of blood in muco-purulent spu- 
tum, which usually comes from an irritated throat. 

Haemoptysis thus defined is seen chiefly in the following condi- 
tions, arranged in the order of frequency: 

1. Phthisis. 

2. Pulmonary congestion with infarction (mitral disease). 

3. Pneumonia. 

4. After epistaxis. 

5. Abscess or gangrene of the lung. 

6. Without known cause ("vicarious menstruation/' etc.). 
Rare causes are new growths of the lung, parasites (Distomum 

Westermanni), aortic aneurism rupturing into an air tube, ulcer of 
the trachea or bronchi. 

The cause of haemoptysis can usually be made out by a thor- 
ough examination of the chest and a study of the other symptoms in 
the case. In phthisis there are often no physical signs in the lungs 
at the period when the bleeding occurs or for some weeks after it. 
Blood coughed up can usually be distinguished from blood vomited 
(hcematemesis) by careful questioning and by examining the blood. 
Blood coughed up often contains bubbles of air and is alkaline in 



326 PHYSICAL DIAGNOSIS. 

reaction, while blood from the stomach is usually mixed with food, 
not frothy, and perhaps acid in reaction. 

(b) Pneumonic Sputum. — The color is most characteristic; it is 
either 

(1) Tawny-yellow or fawn-colored ("rusty"), or 

(2) Orange-juice colored (not orange, but pale straw colored). 
These colors, associated with great tenacity, so that the sputum 

clings to the lips and does not fall from an inverted sputum-cup, 
are almost pathognomonic of pneumonia — though pneumonia often 
occurs without any such sputa. 

(c) Serous sputum, profuse and watery, is characteristic of pul- 
monary oedema. 

(d) Black or gray sputum is due to carbon, dust, or tobacco smoke 
inhaled. 

(e) Pure pus — not muco-purulent — is oftenest seen in influenza, 
occasionally in empyema breaking through the lung. 

(/) Muco-purulent sputum occurs in many diseases and is char- 
acteristic of none. 

IV. Microscopic Examination. — Ninety-nine-one-hundredths of 
all examinations are for the tubercle bacillus. Of the many useful 
methods of staining for this organism the following seems to me 
the best : 

1. Pick out with forceps the most purulent portion of the 
sputa and smear it thinly over a cover glass. All particles thick 
enough to be opaque should be removed from the cover glass be- 
fore staining. 

2. Dry the preparation held in the fingers over a Bunsen or al- 
cohol flame. Then fix it in Cornet's forceps and pass it three times 
through the flame, sputum side down. 

3. Flood it with carbolic fuchsin, 1 and steam it — do not boil it 
— over the flame for about thirty seconds. Be sure to use enough 
stain so that it does not dry on the cover glass. 

4. Wash in water and decolorize for twenty seconds in twenty - 
per-cent H 2 S0 4 . 

1 Carbolic-acid crystals, 5 gm. ; fuchsin (saturated alcoholic solution), 10 
gm. ; water, 100 gm. 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 327 

5. Wash in water and then in ninety-five-per-cent alcohol for 
thirty seconds or until the color ceases to come out. 

6- Wash in water and cover with Lofner's methylene blue ' for 
about thirty seconds. 

7. Wash in water, dry on blotting paper, and mount in Canada 
balsam. 

The whole process need not take more than five minutes, and 
it is absolutely essential that every physician should be familiar 
with it. 

The bacilli are stained red, everything else blue. They should 
be looked for only with an immersion lens (one-twelfth-inch), a 
wide-open diaphragm, and a good white light. In the vast major- 
ity of cases the bacilli are found, if at all, within a few minutes 
and in almost every field. Occasionally one has to search longer, 
but it is better to search one well-stained preparation thoroughly 
than to spend the time in preparing and examining several. 

The presence of red- stained bacilli in specimens of sputa so pre- 
pared is practically pathognomonic of tuberculosis. Other acid- 
resisting bacilli occur in the urine, but almost never in the lung. 

The absence of tubercle bacilli after at least six examinations of 
satisfactory specimens 2 obtained several days apart makes it very 
unlikely that phthisis is present. One or two negative examina- 
tions are of no significance. 

Pneumococcic and Influenza Bacilli. — For both these organisms 
Gram's stain is on the whole the best. This is performed as fol- 
lows: 

1. Prepare a smear as above directed. 

2. Cover it with aniline-oil-gentian-violet solution 3 (freshly 
made each week) and heat to steaming point. 

1 Saturated alcoholic solution of methylene blue, 30 c.c. ; aqueous solution 
of KOH (1 in 10,000), 100 c.c. 

2 A satisfactory specimen is one prepared without any slips in technique 
from purulent sputa obtained by coughing and not by hawking. 

3 Saturated alcoholic solution of gentian violet, 13 c.c. ; aniline water, 84 
c.c. ; aniline water is the clear filtrate from the mixture of aniline, 5 parts, 
with water, 25 parts. 



328 



PHYSICAL DIAGNOSIS. 



3. Wash in water and cover with IK I solution 1 for thirty sec- 
onds. 

4. Wash in ninety-five-per-cent alcohol until the blue color 
ceases to come out. 

5. Counters tain with Bismarck brown for thirty seconds. 

6. Wash in water and mount in Canada balsam. 

The pneumococcus with this stain comes out blue-black and 
its morphology is well shown (see Fig. 166). The presence of a 




Fig. 166.— Pneumococci in Sputum. (W. H. Smith.) (Gram's stain.) 



few pneumococci free in the sputum is not of importance. When 
the organisms are very abundant, and especially when many of 
them are contained within leucocytes, a pneumococcus infection is 
strongly suggested, though it may be a pneumococcus bronchitis 
without pneumonia. In the earliest stages of an infection fewer 

1 Iodine, 1 gm. ; potassium iodide, 2 gm. ; water, 300 c.c. 



EMPHYSEMA, ASTHMA, PULMONARY SYPHILIS, ETC. 329 

organisms are found within leucocytes than is the case later. Ob- 
viously one can learn only by practice what is meant by " few " or 
"many" organisms. 

The influenza bacillus is the smallest organism to be found in 
the sputum. In specimens stained by Gram's method (as above 
given) the influenza bacilli come out as minute, faintly brown-stained 
points, contrasting ivith the intense blue-black of pneumococci and 
other organisms. Only when present in large numbers both inside 
and outside the leucocytes of the sputa are they diagnostic of active 
influenzal infection, since the organism is a common inhabitant of 
the upper air passages. 

Although other organisms — actinomyces, micrococcus catarrhalis, 
streptococcus, bacillus mucosus capsulatus — are sometimes found in 
sputa, their importance does not justify an account of them here. 

Indications for Sputum Examination. — Any cough with sputa 
lasting more than a week calls for an examination of sputa. In 
doubtful cases of influenza or pneumonia, and in any case in which 
tuberculosis is suspected, an examination is imperative. 

When the symptoms or physical signs suggest tuberculosis but 
no sputa can be obtained, it is well to stimulate the bronchial secre- 
tions with 10 gr. of potassium iodide after meals for a week. A 
way of getting sputa from young children has already been de- 
scribed (page 324). 



CHAPTER XVI 

DISEASES AFFECTING THE PLEUKAL CAVITY. 

I. Hydrothorax. 

In cases of nephritis or of cardiac weakness due to valvular 
heart disease a considerable accumulation of serum may take place 
in both pleural cavities. The physical signs are identical with 
those of pleuritic effusion (see below, page 336) except that the 
latter is almost always unilateral, while hydrothorax is usually bi- 
lateral. Exceptions to this rule occur, however, especially on the 
right side or in cases in which one pleural cavity has been obliter- 
ated by fibrous adhesions, the results of an earlier pleurisy. The 
fluid obtained by tapping in cases of hydrothorax is usually con- 
siderably lower in specific gravity and poorer in albumin than tha,t 
exuded in pleuritic inflammation. 

The fluid shifts more readily with change of position than is the 
case with many pleuritic effusions, owing to the absence of adhe- 
sions in hydrothorax. 

Friction sounds, of course, do not occur, as the pleural surfaces 
are not inflamed. A few grains of potassium iodide by mouth soon 
produce a reaction for iodine in the fluid of hydrothorax and not in 
pleuritic effusion. 

II. Pneumothorax. 

Pneumothorax, or the presence of air in the pleural cavity, may 
result from stabs or wounds of the chest wall, but is usually a com- 
plication of pulmonary tuberculosis which weakens the lung until 
by a slight cough or even by the movements of ordinary respiration 
the pulmonary pleura is ruptured and air from within the lung leaks 
into the pleural cavity. 

If the opening is of considerable size, and the air is not hindered 



DISEASES AFFECTING THE PLEURAL CAVITY. 331 

or encapsulated by adhesions, great and sudden dyspnoea with pain 
and profound " shock " may result. More commonly the air enters 
the pleural cavity gradually, the other lung has time to hyper- 
trophy, and the heart and other organs become gradually accus- 
tomed to their new situations. 

Physical Signs. 

1. Inspection. — The affected side may lag behind considerably in 
the movements of respiration. In very marked cases it is almost 
motionless and the interspaces are more or less obliterated. The 
diaphragm is much depressed and Litten's sign absent. In right- 
sided pneumothorax, which is relatively rare, the liver is depressed 
and the edge can be felt below the ribs. 

The heart is displaced as by pleuritic effusion, but usually to a 
less extent. With left-sided pneumothorax the cardiac impulse 
may be lowered as well as displaced, owing to the descent of the 
diaphragm. 

2. Palpation. — Fremitus is absent over the lower portions of the 
chest corresponding to the effused air. At the summit of the chest 
over the retracted lung, fremitus may be normal or increased. In 
rare cases when the lung is adherent to the chest wall and cannot 
retract, fremitus is preserved. 

The positions of the heart and liver are among the most impor- 
tant points determined by palpation. Not infrequently no cardiac 
impulse is to be obtained. Sometimes it may be felt to the right 
of the sternum (see Fig. 167) or in the left axilla, but not infre- 
quently it is so fixed by pleuropericardial adhesions that it is drawn 
upward toward the retracted lung or remains near its normal situa- 
tion. The liver is greatly depressed in cases of right-sided pneumo- 
thorax, and may be felt as low as the navel. 

3. Percussion. — 'Loud tympanitic resonance is the rule through- 
out the affected side. Even a small amount of air is sufficient to ren- 
der the whole side tympanitic and often to obscure the dulness which 
the frequently associated pleural effusion would naturally produce. 
Indeed, it is the rule that small effusions are wholly masked by the 
adjacent tympany. 



332 PHYSICAL DIAGNOSIS. 

In no other disease do we get such clear, intense tympanitic 
resonance over the chest. 

The only exception to this rnle occurs in cases in which the air 
within the chest is under great tension, making the chest walls so 
taut that, like an over-stretched drum, they cannot vibrate properly. 
Under these conditions the percussion note becomes muffled, at 
times almost dull. 

Areas of dulness corresponding to the displaced organs (heart 
or liver) may sometimes be percussed out. 

4. Auscultation. — Respiration and voice sounds are usually in- 
audible in the lower portions of the chest. At the top of the chest, 
and rarely in the lower parts, a faint amphoric or metallic breathing 
may be heard, but as a rule the amphoric quality is brought out 
much better by cough which is followed by a ringing after-echo. 
Or the air in the pleura may be set to vibrating and made to give 
forth its characteristic, hollow, ringing sound if a piece of metal 
{e.g., a coin) be placed on the back of the chest and struck with 
another coin, while we listen with the stethoscope over the front of 
the chest opposite the point where the coin is. 

The clear ringing sound heard in this way is quite different 
from the dull chink obtainable over sound lung tissue. 

The " falling- drop sound" or "metallic tinkle," and the lung 
fistula sound are occasionally audible (see above, p. 170). 

On the sound side the breath sounds are exaggerated. At the 
top of the affected side over the collapsed lung the breathing is 
bronchial and rales are occasionally heard. 

In the great majority of cases pneumothorax is complicated by 
an effusion of fluid in the affected pleural cavity and we have then 
the signs of 

III. Pneumoserothorax or Pnetjmopyothorax 

When both fluid and air are contained in the pleural cavity, the 
patient may himself be able to hear the splashing sounds which 
the movements of his own body produce. These are more readily 
appreciated if the observer puts his ear against the patient's chest 
and then shakes him briskly. Splashing sounds heard within the 



DISEASES AFFECTING THE PLEURAL CAVITY. 



333 



chest are absolutely pathognomonic and point only to the combina- 
tion of fluid and air within the pleural cavity. One must distin- 
guish them, however, from similar sounds produced in the stomach. 
By observing the position of maximum intensity of the sounds, this 
distinction may be easily made. Unfortunately the critical condi- 
tion of the patient may make it impossible to try succussion, as in 
the acute cases with great shock it is dangerous to move him at all. 







"': 




,-,- - • 






^^Er ' "' JhH^H 








.•'"•'.'- : .' ' •'" '}} 














'•-'fijBpjij 
















', '' : • ■■ ~.\6- : '' ■~i'-£: : --'. 






i ■.':':'•-.' ':'"■ )'!- 


i> : l i 













Fig. 167.— Pneumoserothorax Seen from Behind. Note the horizontal line at the surface of the 
fluid and the retracted lung just above the inner half of this line. Compare Fig. 173. 
(From v. Ziemssen's Atlas.) 



The movements of breathing or coughing may bring out a " metal- 
lic tinkle " (see above, p. 332). At the base of the chest, over an 
area corresponding to the position of the fluid, an area of dulness 
may be easily marked out by percussion, and this area shifts very 
markedly with change of position. The shifting dulness of pneu- 
moserothorax is strongly in contrast with the difficulty of obtain- 
ing any such shift in ordinary pleuritic effusion (see Fig. 168). 



334 



PHYSICAL DIAGNOSIS. 



(The distinction between "open pneumothorax,' 3 in which the 
rent in the lung through which the air escaped in the pleura re- 
mains open, and "closed pneumothorax ■," in which the rent has 
become obliterated — is one which cannot be established by physi- 
cal signs alone. It is often said that amphoric breathing, and espe- 
cially an amphoric ring to the voice and cough sounds, denote an 



Exaggerated 
resonance and 
breathing. 



Displaced- cardiac 
impulse. 




Tuberculous so- 
"' lidiflcation. 



f Tympany ; 
( absent voice ; 
Air= < breathing ab- 
/ sent or distant 
I amphoric. 



Dulness, shifting 
with change of po- 
sition^ (fluid). 



Fig. 168. - Pneumoserothorax with Displaced Heart. 



open pneumothorax, but post-mortem evidence does not bear this 
out. Practically an open pneumothorax is one in which the 
amount of effused air increases, and closed pneumothorax is one in 
which the physical signs remain stationary.) 

Differential Diagnosis. 

The distinction between pneumothorax and emphysema has al- 
ready been discussed. 

(a) When the air in the pleural sac is under such tension that 
the percussion note is dull, the physical signs may simulate pleu- 
ritic effusion, but real flatness, such as characterizes effusion, has 
not, so far as I know, been recorded in pneumothorax, and the 
sense of resistance on percussing is much greater over fluid than 
over air. In case of doubt puncture is decisive. 



DISEASES AFFECTING THE PLEURAL CAVITY. 335 

(b) Acute pneumothorax, coming on as it does with symptoms 
of collapse and great shock, may be mistaken for angina pectoris, 
cardiac failure, embolism of the pulmonary artery, or acute pulmo- 
nary tympanites (see above, p. 315). 

From all these it can be distinguished by the presence of am- 
phoric or metallic sounds, which are never to be obtained in the 
other affections named. 



Fig. 169.— Diaphragmatic Hernia. The outline of the displaced diaphragm visible below the 
left clavicle. Heart displaced to right of sternum. (From v. Ziemssen's Atlas.) 

(c) Hernia of the intestine through the diaphragm (see Fig. 169) 
or great weakening of the diaphragmatic muscular fibres, may allow 
the intestines to encroach upon the thoracic cavity and simulate 
pneumothorax very closely. The history and course of the case, the 
abdominal pain, vomiting, and indicanuria, generally suffice to dis- 
tinguish the condition. The peristalsis of the intestine may go on 
even in the thorax, and gurgling metallic sounds corresponding to it 
and unlike anything produced in the thorax itself may be audible. 



336 PHYSICAL DIAGNOSIS. 

The distinction between open and closed pneumothorax, to which 
I have already alluded, is far less important than the presence or 
absence of 

(a) Pulmonary tuberculosis 

(b) Encapsulating adhesions in which the air is confined to a 
circumscribed area 

(a) The examination of the sputa and of the compressed lung 
may yield evidence regarding tuberculosis. On the sound side the 
compensatory hypertrophy covers up foci of dulness or rales so that 
it is difficult to make out much. 

(b) Encapsulated pneumothorax gives us practically all the signs 
of a phthisical cavity, from which it is distinguished by the fact 
that with a cavity the nutrition of the patient is almost always 
much worse. 

Encapsulated pneumothorax needs no treatment. Hence the 
importance of distinguishing it from the non-encapsulated form of 
the disease, in which treatment is essential. 

PLEUEISY. 

Clinically, we deal with three types : 

(a) Dry or plastic pleurisy. 

(b) Pleuritic effusion, serous or purulent. 

(c) Pleural thickening. 

(a) Dry or Plastic Pleurisy. 

Doubtless many cases run their course without being recognized. 
The frequency with which pleuritic adhesions are found post mor- 
tem would seem to indicate this. 

It is usually the characteristic stitch in the side which suggests 
physical examination. The pain and the physical signs resulting 
from the fibrinous exudation are usually situated at the bottom of 
the axilla where the diaphragmatic and costal layers of the pleura 
are in close apposition. Doubtless the pleuritic inflammation is 
not by any means limited to this spot, but it is here that the two 
layers of the pleura make the largest excursion while in apposition 
with each other. In the vast majority of cases, then, the physical 
signs are situated at the spot indicated in Fig. 170. 



DISEASES AFFECTING THE PLEURAL CAVITY. 



337 



Occasionally pleuritic friction is to be heard in the precordial 
region, and after the absorption of a pleuritic effusion evidences 
of fibrinous exudation in the upper parts of the chest are sometimes 
demonstrable. Most rarely of all, evidence of plastic pleurisy may 
be found at the apex of the lung in connection with early phthisis. 
In diaphragmatic pleurisy, when the fibrinous exudation is espe- 
cially marked upon the diaphragmatic pleura, friction sounds may 
be heard over the region of the attachment of the diaphragm in 
front and behind as well as in the axillae. Hiccup often occurs and 
gives exquisite pain. 

Our diagnosis is based upon a single physical sign, pleuritic 
friction. The nature of this sound and the 
manoeuvres for eliciting it have already 
been described (see above, p. 166), and I 
will here only recapitulate what was there 
said. During the first few deep breaths 
one hears, while listening over the painful 
area, a grating or rubbing sound usually 
somewhat jerky and interrupted, most 
marked at the latter part of inspiration, 
but often audible throughout the whole 
respiratory act. After a few breaths it 
often disappears, but will usually reap- 
pear if the patient lies for a short time 
upon the affected side, and then sits up 
and breathes deeply. In marked cases 
the rubbing of the inflamed pleural sur- 
faces may be felt as well as heard, and it 
is not very rare for the patient to be able 
to feel and hear it himself. Pleuritic fric- 
tion may be present and loud without 
giving rise to any pain. On the other 
hand, the pain may be intense, and yet 
the friction-rub barely audible. When 
heard at the summit of the chest, as in 
cases of incipient phthisis, pleural fric- 




FiG. 170— Showing the Point at 
which Pleural Friction is most 
Often Heard. 



22 



338 PHYSICAL DIAGNOSIS. 

tion produces only a faint grazing sound, much more delicate and 
elusive than the sounds produced at the base of the chest. 

Occasionally the distinctive rubbing or grating sounds are more 
or less commingled with or replaced by crackling sounds indistin- 
guishable from the drier varieties of rales. It is now, I think, 
generally believed that such sounds may originate in the pleura as 
well as within the lung. The greatest care should be taken to 
prevent any shifting or slipping of the stethoscope upon the surface 
of the chest, as by such means sounds exactly like those of pleural 
friction may be transmitted to the ear. In case of doubt one 
should always wet or grease the skin so that the stethoscope can- 
not slip. 

Muscle sounds are sometimes taken for pleural friction, but they 
are bilateral, usually low-pitched, sound less superficial than pleu- 
ral friction, and are not increased by pressure. When listening 
for friction at the base of the left axilla, I have once or twice been 
puzzled by some low-pitched rumbling sounds occurring at the end 
of inspiration, and due (as afterward appeared) to gas in the stom- 
ach which shifted its position with each descent of the diaphragm. 

In children friction sounds and pleuritic pain are much less 
common than in adults, and the signs first recognizable are those 
of effusion. In adults the presence of a very thick layer of fat 
may make it difficult or impossible to feel or hear pleural friction. 

The breath sounds over the affected area are usually absent 01 
greatly diminished, owing to the restraint in the respiratory move- 
ments due to pain. Not infrequently pleuritic friction may be 
heard altogether below the level of the lung. 

(b) Pleuritic Effusion. 

Many cases are latent, and the patients consult the physician on 
account of slight cough, weakness, or gastric trouble, so that the 
effusion is first discovered in the course of routine physical ex- 
amination. Since it is usually the results of percussion which first 
put us on the right track, I shall take up first 



DISEASES AFFECTING THE PLEURAL CAVITY. 339 

Percussion. 

1. A small effusion first shows as an area of dulness 

(a) Just below the angle of the scapula. 

(b) In the left axilla between the fifth and the eighth rib. 

(c) Obliterating Traube's semilunar area of tympany; or 

(d) In the right front near the angle made by the cardiac and 
hepatic lines of dulness (see Fig. 171). 

In the routine percussion of the chest, therefore, one should 
never leave out these areas. A small effusion is most easily de- 
tected in children or in adults with thin chest walls, provided our 
percussion is not too heavy. An effusion amounting to a pint 
should always be recognizable, and smaller amounts have frequently 
been diagnosed and proved by puncture. 

The amount of a pleuritic effusion is roughly proportional to 
the area of dulness on percussion, but not accurately. It is very 
common to find on puncture an amount of fluid much greater than 



Area of dulness 

due to small -<■- f- 

pleural effusion. 




Area of cardiac 
dulness. 



Fig. I71.-Small Pleural Effusion Accumulating (in part) near the Right Border of the Heart. 



could have been suspected from the percussion outlines ; on the other 
hand, the dulness may be extensive and intense on account of great 
inflammatory thickening of the costal pleura, by the accumulation 



340 



PHYSICAL DIAGNOSIS. 



of layer after layer of fibrinous exudate and its organization into 
fibrous plates, while very little fluid remains within. 

The amount of dulness depends also upon the thickness and elasti- 
city of the chest wall and the degree of collapse of the lung within. 

2. Large Effusions. — T\ T hen the amount of fluid is large, the dul- 
ness may extend throughout the whole of one side of the chest with 
the exception of a small area above the clavicle or over the primary 
bronchus in front, This area gives a high-pitched tympanitic note, 



Normal resonance 
and vesicular 
breathing. 



Tympany, voice and 
fremitus in- 
creased. 



Flatness, no breath- 
ing, voice sounds, 
or fremitus. 




Zone of condensed 
lung above the 
fluid. 



Exaggerated (com- 
pensatory) breath- 
ing and reso- 
nance. 



FIG. 172.-Diagram to Illustrate Physical Signs in Moderate-Sized Effusion in the Left Pleura, 



provided the bronchi remain open, as they almost always do. This 
tympany is high-pitched and sometimes astonishingly clear. I re- 
cently saw a case in which the note above the clavicle was almost 
indistinguishable with the eyes shut from that obtained in the epi- 
gastrium. Occasionally " cracked-pot " resonance may be obtained 
in the tympanitic area. 

The pitch changes if the patient opens and closes his mouth 
while we percuss ("Williams' tracheal tone"). 

The dulness over the lower portions of a large effusion is usual- 
ly very marked, and the percussing finger feels a greatly increased 



DISEASES AFFECTING THE PLEURAL CAVITY. 



341 



resistance to its blows when compared with the elastic rebound of 
the sound side. 

3. Moderate Effusions. — Three zones of resonance can often be 
mapped out in the back: at the base dulness or flatness, above 
that a zone of mingled dulness and tympany, and at the top normal 
resonance. The lowest zone corresponds to the fluid, the middle 
zone to the condensed lung immediately above it, and the top zone 
to the relatively unaffected part of the lung (see Fig. 172). Not 
infrequently there is no middle zone but simply dulness below and 
resonance above, as is usually the case in the axilla and front. 




Fig. 173. — Left Pleural Effusion. Note that the surface of the fluid slopes outward and up- 
ward from the median line. (From v. Ziemssen's Atlas.) 



The position of the effusion depends only in part upon the in- 
fluence of gravity, and is greatly influenced by capillarity and the 
degree of retraction of the lungs. Consequently the surface of 
the fluid is hardly ever horizontal except in very large accumula- 



342 PHYSICAL DIAGNOSIS. 

tions. With, the patient in an upright position it usually reaches 
a higher level in the axilla than in the back (see Fig. 173). Near the 
spine and near the sternum (in right-sided effusions) the line corre- 
sponding to the level of the fluid may rise sharply. 

The S-curve of Ellis, as worked out so elaborately by Garland, 
varies still further the uneven line which corresponds to the sur- 



Triangular space 
dull until patient 
has coughed and 
breathed deeply. 



Area of dulness 
bounded above by 
the S-curve of 

Ellis. 




Fig. 174.— The S-Curve of Ellis. 

face of the fluid (see Fig. 174). This curve can be obtained only 
after the patient has, by cough and forced breathing, expanded the 
lung as fully as possible. 

All these curves are to be found with the patient in the upright 
position. 'None of them has any considerable diagnostic impor- 
tance, and the chief point to be remembered is that the upper sur- 
face of the fluid, not being settled by gravity alone, is hardly ever 
horizontal. 

With change in the position of the patient the level of the fluid 
sometimes changes very slowly and irregularly, and sometimes does 
not change at all. If, for purposes of thorough examination, we 
raise to a sitting posture a patient who has been for some days or 
weeks in bed, we should never begin the examination at once, since 



DISEASES AFFECTING THE PLEURAL CAVITY. 343 

it may .take some minutes for the lungs and the fluid to accommo- 
date themselves to the new position. It is well also to get the 
patient to cough and to take a number of full breaths before the 
examination is begun. 

To test the mobility of the fluid with change of the patient's 
position, mark out the upper limit of the dulness in the back with 
the patient in the upright position. Then let the patient lie face 
downward upon a couch, and, after waiting a few minutes, percuss 
the previously dull area. It may be found to have become resonant. 1 

When the fluid is absorbed or removed by tapping, one would 
expect an immediate return of the percussion resonance. But in 
fact the resonance returns very slowly and is wholly unreliable as 
a test of the amount of absorption which has occurred. Thickened 
pleura and atelectatic lung may abolish resonance long after the 
fluid is all gone. We depend here far more upon the evidence ob- 
tained by auscultation and palpation and on the general condition 
of the patient. 

To determine the returning elasticity of the lung and the degree 
of movability of its lower border, percussion is very useful during 
the stage of absorption. After percussing out the lower border of 
pulmonary resonance in the back, the patient is directed to take a 
long breath and hold it. If the lung expands, the area of percus- 
sion resonance will increase downward. 

Percussion aids us in determining whether neighboring organs 
are displaced by the pressure of the accumulated fluid. The liver 
is often pushed down, the spleen very rarely. Dislocation of the 
heart is one of the most important of all the signs of pleural effu- 
sion, and is often the crucial point in differential diagnosis. It is 
a very striking and at first surprising fact that a left-sided effusion 
displaces the heart far more than a right-sided effusion of the same 

1 This test, however, is somewhat fallacious and of yery little diagnostic 
value, since the lungs tend to swing up toward the back when the patient lies 
prone, even when no fluid is present, and increase of resonance in the back with 
this change of position might, therefore, occur when the dulness was due to 
thickened pleura and not to fluid. 



344 PHYSICAL DIAGNOSIS, 

size. Small or moderate right-sided effusions often do not displace 
the heart at all. 

With left-sided effusions, unless very small, we find the area of 
cardiac dulness shifted toward the right and often projecting be- 
yond the right edge of the sternum (see Fig. 173). (Inspection and 
palpation often give us even more valuable information on this 
point. See below, p. 347.) We must be careful to distinguish such 
an area of dulness at the right sternal margin from that which may 
be produced in right-sided effusions by the fluid itself (see above). 

As mentioned above, a right pleural effusion may very early 
show itself as an area of dulness along the right sternal margin. 
Light percussion will usually demonstrate that this dulness is con- 
tinuous with a narrow strip of flatness at the base of the axilla 
(ninth and tenth ribs). Such an effusion is late in creeping up the 
axilla. It appears first and disappears first along the right margin 
of the sternum. 

On the sound side the percussion resonance is often increased, 
owing to compensatory hypertrophy of the sound lung; the dia- 
phragm is pushed down and the borders of the heart or of the liver 
may be encroached upon. When the hyper-resonance of the sound 
side is present, it should warn us to percuss lightly over the effu- 
sion, else we may bring out the resonance of the distended lung. 

Summary of Percussion Sigyis. — (1) Flatness corresponding 
roughly to the position of the fluid. 

(2) Tympany above the level of the fluid over the condensed 
lung. 

(3) The level of the fluid is seldom quite horizontal. 

(4) Shifting of the fluid with change of position is rare, slow, 
and has little or no importance in diagnosis. 

Exceptions and Possible Errors. — (a) Great muscular pain and 
spasm may produce an area of dulness which simulates that of 
pleural effusions, especially as the auscultatory signs may be equally 
misleading. A hypodermic of morphine will dispel the dulness 
along with the pain if it is due to muscular cramp. 

(h) If the lung on the affected side fails to retract (owing to 



DISEASES AFFECTING THE PLEURAL CAVITY. 345 

emphysema or adhesions to the chest wall), the area of dulness and 
its intensity will be much diminished. 

(c) It must be remembered that dulness in Traube's space may 
be due to solidification of the lung, to situs inversus, to tumors, or to 
overfilling of the stomach and intestine with food, as well as to 
pleural effusion; also that the size of the tympanitic space varies 
greatly in health. 

(d) Barely percussion may be tympanitic over an effusion at 
the left base owing to distention of the stomach or colon. 

(e) The diagnosis between fluid and thickened pleura will be 
considered later. 

Auscultation. 

The auscultatory phenomena vary greatly in different cases, and 
in the same case at different times, because the essential condi- 
tions are subject to similar variations Whatever sounds are pro- 
duced in the lungs or in the bronchi may be heard over the fluid un- 
less interfered with by inflammatory thickening of the costal pleura. 
Fluid transmits sounds well, but there may be no breath sounds pro- 
duced and hence none audible over the fluid. Or tubular sounds 
only may be produced because only the bronchi remain open, the 
rest of the lung being collapsed. 

Or again, if rales or friction sounds are produced in the lung, 
they, too, may be transmitted to the fluid and may (alas !) deter 
the timid " observer " from tapping. 

In about two-thirds of all large effusions no breathing at all is 
audible over the area of flatness on percussion. In the remaining 
third, and especially in children, tubular breathing, sometimes 
feeble, sometimes very intense, is to be heard.. 

In moderate effusions there are often three zones in the back. 
At the bottom we hear nothing, in the middle zone distant bron- 
chial or broncho-vesicular breathing, while at the summit of the 
chest the breathing is normal. 

The voice sounds correspond When breath sounds are absent, 
the voice sounds are likewise absent. When the breathing is tubu- 



346 PHYSICAL DIAGNOSIS. 

lar, the voice, and especially the whisper, is also tubular and inten- 
sified. That is, whenever the bronchi are open, the lung retracted, 
and the chest walls thin, the breathing, voice, and whisper will corre- 
spond to the tracheal and bronchial sounds. Since children have es- 
pecially thin chest walls, these bronchial sounds are especially fre- 
quent and intense in children. 1 

Near the angle of the scapula and in a corresponding position 
in front, the sound of the spoken voice may have a peculiar high- 
pitched, nasal twang, to which the term egophony is applied. 
This sign has no importance in diagnosis, since it is not constant, 
and not peculiar to fluid accumulations. 

Kales are rarely produced in the retracted lung, and so are 
rarely to be heard over the fluid. 

All these sounds may be diminished or abolished if the costal 
pleura is greatly thickened 

The influence of cough upon the lung, and so upon the sounds 
produced in it and transmitted through the fluid, may be very great 
and very puzzling. Rales may appear or disappear, breathing 
change in quality or intensity, and in the differential diagnosis of 
difficult cases the patient should always be made to cough and then 
breathe deeply before the examination is completed. 

In very large effusions, when only the primary bronchi are 
open, there may be signs like those of pulmonary cavity at the site 
of the bronchi in front or behind (amphoric breathing, large metallic 
rales, etc.). Over the sound lung the breathing is exaggerated and 
extends unusually far down in the back and axilla, owing to hyper- 
trophy of the lung. 

The heart sounds may be absent at the apex owing to disloca- 
tion of the heart. In left-sided effusions the apex sounds are often 
loudest near the ensiform cartilage or beyond the right margin of 
the sternum. Eight-sided effusions have much less effect upon the 
heart, but occasionally we find the heart sounds loudest at the left 
of the nipple or in the axilla. 

Since many cases of pleural effusion are due to tuberculosis, we 

' Bacelli's theory— that the whispered voice is conducted through serum 
but not through pus — is not borne out by facts. 



DISEASES AFFECTING THE PLEURAL CAVITY. 347 

should never omit to search for evidences of this disease at the 
apex of the lung on the sound side, since experience has shown that 
phthisis is more apt to begin here than on the side of the effusion. 

Summary of Auscultatory Signs. 

(1) In most cases voice and breath sounds are absent or very- 
feeble over the area occupied by the fluid. 

(2) In a minority of the cases the breathing and voice sounds 
may be tubular and intensified, especially in children. 

(3) Over the condensed lung at the summit of the chest the 
breathing is bronchial or broncho-vesicular, according to the degree 
of condensation. If the amount of fluid is small, the layer of con- 
densed lung occupies the middle zone of the chest and the breath- 
ing is normal at the top of the chest. 

(4) Bales and friction sounds are rarely heard over fluid. 

(5) On the sound side the breathing is exaggerated. 

(6) The heart sounds may be absent at the apex and present in 
the left axilla or to the right of the sternum owing to dislocation 
of the heart. 

Inspection and Palpation. 

The most important information given us by inspection and 
palpation relates to the displacement of various organs by the pres- 
sure of the accumulated fluid. In left-sided pleuritic effusions the 
heart is usually displaced considerably toward the right, even when 
the level of the fluid reaches no higher than the sixth rib in the 
nipple line. The apex impulse is to be seen and felt to the right 
of the sternum, somewhere between the third and the seventh rib, 
when a large amount of fluid is present. With smaller effusions 
one may find the apex beat lifting the sternum or close to its left 
border. The position of the heart may be confirmed by percussion. 

The spleen is scarcely ever displaced. 

Eight-sided effusions are far less likely to displace the heart, and 
it is only when a large amount of fluid is present that the apex of 
the heart is pushed outward beyond the nipple. Moderate right- 
sided effusions often produce no dislocation of the heart whatever. 
The liver is often considerably pushed down by a right-sided pleu- 



348 PHYSICAL DIAGNOSIS. 

ritic effusion, and its edge may be palpable several inches below the 
costal margin. Its upper margin cannot be determined by percus- 
sion, as it merges into the flatness produced by the fluid accumula- 
tion above it. 

Tactile fremitus is almost invariably absent or greatly dimin- 
ished over the areas corresponding to the fluid ; just above the level 
of the fluid it is often increased. 

Occasionally a slight fulness of the affected side may be recog- 
nized by inspection, and the interspaces may be less readily visible 
than upon the sound side. Bulging of the interspaces I have never 
observed. When the accumulation of fluid is large the respiratory 
movements upon the affected side are somewhat diminished, 1 the 
shoulder is raised, and the spine curved toward the affected side. 
The diaphragm is depressed, and Litten's sign therefore absent. 

There are no reliable means for distinguishing purulent from 
serous effusions. The whispered voice may be transmitted through 
either pus or serum. But we know that in children two-thirds of 
all effusions are purulent, while in adults three-fourths of them are 
serous. 

Physical Signs During Absorption of Pleural Effusions. 

When the fluid begins to disappear, either spontaneously or as 
a result of treatment, the dulness very gradually disappears and 
the breath sounds, voice sounds, and fremitus reappear. In case 
the heart has been dislocated, its return to its normal position is 
often much slower than one would anticipate, and indeed all the 
physical signs are disappointingly slow to clear up even after tap- 
ping. Pleural friction appears when the roughened pleural surfaces, 
which have been held apart by the fluid, are allowed by the disap- 
pearance of the latter to come into apposition again. Owing to pul- 
monary atelectasis and permanent thickening of the pleura, con- 
siderable dulness often remains for weeks after the fluid has been 
absorbed. 

1 1 have purposely made but little of the changes in the shape of the chest 
produced by pleuritic effusions, as it has seemed to me that by far too much 
stress has usually been laid upon such signs. 



DISEASES AFFECTING THE PLEURAL CAVITY. 349 

(c) Pleural Thickening. 

In persons who have previously suffered from pleurisy with 
effusion, and in many who have never to their knowledge had any 
such trouble, a considerable thickening of the pleural membrane 
with adhesion of the costal and visceral layers may be manifested 
by the following signs : 

(1) Dulness on percussion, sometimes slight, sometimes marked. 

(2) Diminished vesicular respiration. 

(3) Diminished voice sounds and tactile fremitus. 

(4) Absence of Litten's phenomenon and diminution in the 
normal respiratory excursion of the chest. 

These signs are most apt to be found at the base of the lung 
behind and in the axilla. Occasionally a similar thickening may 
be demonstrated throughout the whole extent of the pleura, and the 
lung failing to expand, the chest may fall in as a result of atmos- 
pheric pressure (see Fig. 51). 

The ribs approximate and may overlap, the spine becomes 
curved, the shoulder lowered, the scapula prominent, and the whole 
side shrunken. The heart may be drawn over toward the affected 
side. 

In the diagnosis of pleural thickening Rosenbach's "palpatory 
puncture " is sometimes our only resource. Under antiseptic pre- 
cautions a hollow needle is pushed between the ribs and into the 
pleural cavity. As the needle forces its way through the tough 
fibrous, or perhaps calcified, pleura, the degree and kind of resist- 
ance are very enlightening. Again, the amount of mobility of the 
point after the chest wall has been pierced tells us whether the 
needle is free in a cavity, entangled in a nest of adhesions, or fixed 
in a solid " carnified " lung. There is no danger if the needle is 
sterile. 

Encapsulated Pleural Effusion. 

Small accumulations of serum or pus may be walled off by ad- 
hesions so that the fluid does not gravitate to the lowest part of 
the pleural cavity or spread itself laterally as it would if free. 



350 PHYSICAL DIAGNOSIS. 

Such localized effusions are most apt to be found in the lower axil- 
lary regions or behind — sometimes between the base of the lung and 
the diaphragm, and more rarely between 'the lobes of one of the 
lungs or higher up. I have twice seen an encapsulated purulent 
effusion so close to the left margin of the heart that the diagnosis 
of pericardial effusion was made. 

The diagnosis of encapsulated pleural effusion is a difficult one 
and oftentimes cannot be made except by puncture. The signs are 
those of fluid in the pleura, but anomalously placed. Even punc- 
ture may fail to clear up the difficulty, since the needle may pass 
entirely through the pouch of fluid and into some structure behind 
so that no fluid is obtained. 

Pulsating Pleurisy (Empyema Necessitatis). 

Under conditions not altogether understood the movements 
transmitted by the heart to a pleural effusion (usually purulent) 
may be visible externally as a circumscribed pulsating swelling near 
the precordial region, or as a diffuse undulation of a considerable 
portion of the chest wall. Sometimes this pulsation is visible be- 
cause the fluid has worked its way out through the thoracic wall 
and is covered only by the skin and subcutaneous tissues, but occa- 
sionally pulsation in a pleural effusion becomes visible, although no 
such perforation of the chest wall has occurred. 

The condition is a rare one, and is of importance only because it 
may be mistaken for an aneurism, from which, however, it should 
be readily distinguished by the absence of a palpable thrill or dias- 
tolic shock and by the evidence of fluid in the pleura. 

Differential Diagnosis of Pleuritic Effusion. 

The following conditions are not infrequently mistaken for 
pleuritic effusion : 

(1) Croupous pneumonia with occlusion of the bronchi. 

(2) Pleural thickening, with pulmonary atelectasis. 

(3) Subdiaphragmatic abscess or abscess of the liver. 

In croupous pneumonia with plugging of the bronchi one may 



DISEASES AFFECTING THE PLEURAL CAVITY. 351 

have present all the physical signs of pleuritic effusion except dis- 
placement of the neighboring organs. The presence or absence of 
such displacement, together with the history, symptoms, and course 
of the case, is therefore our mainstay in distinguishing the two 
diseases. 

From ordinary croupous pneumonia (without occlusion of the 
bronchi) pleuritic effusion differs in that it produces a greater de- 
gree of dulness and a diminution of the spoken voice sounds and 
tactile fremitus. Bronchial breathing and bronchial whisper may 
be heard either over solid lung or over fluid accumulation, although 
the bronchial sounds are usually feeble and distant in the latter 
condition. The displacement of the neighboring organs is of im- 
portance here as in all diagnoses in which pleuritic effusion is a 
possibility. In pleuritic effusion we can sometimes determine that 
the line marking the upper limit of dulness shifts with change of 
the patient's position. This is, of course, impossible in pneumo- 
nia. A few hard coughs may open up an occluded bronchus and 
so clear up the diagnosis at once. In doubtful cases the patient 
should always be made to cough and breathe deeply before the 
examination is finished. 

It should always be remembered that one may have both pneu- 
monia and pleuritic effusion at the same time, and that pneumonia 
is often followed by a purulent effusion. In children the bronchi 
are especially prone to become occluded even as a result of a simple 
bronchitis, and we must then differentiate between atelectasis and 
effusion — in the main by the use of the criteria just described. 

(2) It is sometimes almost impossible to distinguish small fluid 
accumulations in the pleural cavity from pleural thickening with 
pulmonary atelectasis. In both conditions one finds dulness, dimi- 
nution of the voice sounds, respiration, and tactile fremitus, and 
absence of Litten's phenomenon, but the tactile fremitus is usually 
more diminished when fluid is present than in simple pleural thick- 
ening and atelectasis. An area of dulness which shifts with change 
of position points to pleuritic effusion. The presence of friction 
sounds over the suspected area speaks strongly in favor of pleural 
thickening, but it is possible to hear friction sounds over fluid, 



352 



PHYSICAL DIAGNOSIS. 



probably because they are conducted from a point higher up in the 
chest at which no fluid is present. In doubtful cases the diagnosis 
can and should be cleared up by 'puncture. 

(3) In two cases I have known enlargement of the liver due to 
multiple abscesses to be mistaken for empyema. In both condi- 
tions, one finds in the right back dulness on percussion as high as 
mid-scapula, with absence of voice sounds, breath sounds, and 
fremitus. These conditions are due in one case to the presence of 
fluid between the lung and the chest wall, and in the other case to 




Fig. 175.— Area of Dulness in Solitary (tropical) Abscess of the Liver. 



the liver which pushes up the lung together with the diaphragm. 
By physical signs alone I do not see how this diagnosis is possible, 
though Litten's sign may be of use, since the shadow is absent 
in empyema and sometimes present in moderate-sized subdia- 
phragmatic accumulations. Some of the symptoms, such as chills, 
sweating, and irregular fever, are common to both conditions. A 
careful consideration of the history and the associated signs and 
symptoms may help us to decide. 

Large solitary abscess of the liver, occurring as it almost in- 
variably does in the posterior portion of the right lobe, produces an 
area of flatness on percussion, which rises to a much higher level in 



DISEASES AFFECTING THE PLEURAL CAVITY. 



353 



the axilla and back than in front or near the sternum (see Fig. 175), 
and may be in this way distinguished from empyema; but when the 
liver contains many small abscesses, as in suppurative cholangitis, 
this peculiar line of dulness is not present. 

(d) Bare diseases, such as cancer or hydatid of the lung, may 
be mistaken for pleuritic effusion. The history of the case and the 
results of exploratory puncture usually clear up the difficulty. 

Examination of Exudates and Transudates. 

Only such methods as can be carried out without a thermostat 
will be here described. Hence the examination of diphtheria 
swabs, blood cultures, and pus are excluded. We have left the 




Fig. 170.— Lymphocytosis in Pleural Fluid. Primary tuberculous pleurisy. (X 750 diameters.) 

(Musgrave.) 



fluids obtained by tapping the pleura, the peritoneum, and the spinal 
cord. The first is the most important. 
23 



354 PHYSICAL DIAGNOSIS. 

Pleural Fluids. — A fluid withdrawn from the pleura by punct- 
ure may be a mechanical transudate (hydrothorax), may be evi- 
dence of tuberculous pleurisy (primary or associated with phthisis), 
or, rarely, an exudate of septic or cancerous origin. 

To investigate these fluids we note : 

1. Color. Bloody fluids suggest cancer, but occasionally occur 
in pneumonia and tuberculosis. 

2. Weight. 1 Dropsical fluid is generally below 1.015 in specific 






FIG. 177.— Polynuclears and Large Lymphocytes in Pleural Fluid from a Case of Traumatic 
Acute Infectious Pleurisy. (X 750 diameters.) (Musgrave.) 

gravity. Exudates are usually in the vicinity of 1.020. An ordi- 
nary specific-gravity bulb is used. 

3. The cells of the sediment (cytodiagnosis). 

Technique of Cytodiagnosis. — 1. Pour fluid into tubes of a cen- 
trifuge and centrifugalize five minutes. 

2. Pour off the supernatant fluid and stir up the sediment witk 

1 The amount of albumin usually runs parallel with the weight of Ae fluid. 



DISEASES AFFECTING THE PLEURAL CAVITY. 



855 



a platinum loop, so as to suspend the sediment in the few remain- 
ing drops. 

3. Spread a drop of the mixture on a clean cover glass with the 
platinum loop and let the smear dry without heating it. 

4. Stain like a blood film (see below, page 469) with the follow- 




Fig. 178.— Pleural Fluid in Hydrothorax Due to Cardiac Disease. Endothelial plaques and cells. 
(X 750 diameters.) (Musgrave.) 



ing mixture: * Wright's modification of Irishman's stain, 3 parts; 
pure methyl alcohol, 1 part. 

5. After staining, wash very gently, using a dropper (else the 
whole film may be pushed off), and dry in the fingers over a Bun- 
sen or alcoholic flame. Do not blot the preparation. 

6. Mount in Canada balsam and examine with an oil-immersion 
lens. 

Interpretation of Results. — (a) In tuberculous pleurisy, lymph o- 

' Suggested by Musgrave: Boston Med. and Surg. Journ.,vol. cli., p. 319, 1904. 



356 PHYSICAL DIAGNOSIS. 

cytes make up from seventy to ninety-nine per cent — usually over 
ninety per cent — of all the cells found in the smear (see Fig. 176). 

(b) In septic cases due to the streptococcus, staphylococcus, or 
pneumococcus the majority of the cells are polynuclear leucocytes 
(see Fig. 177). 

(c) In transudations (dropsical) the predominating cell is a large 
mononuclear type, apparently endothelial in origin and often occur- 
ring in sheets or "plaques" (see Fig. 178). 

Exceptions occasionally occur, but in the main these rules are 
sufficiently exact to be of value in diagnosis when taken in connec- 
tion with all the facts in the case. 

In peritoneal fluid the use of cytodiagnosis has not as yet fur- 
nished information of any considerable diagnostic value. 

In cerebrospinal fluid obtained by lumbar puncture the predom- 
inance of lymphocytes has not the same association with tuberculo- 
sis as it has in the pleura, and seems to point to nothing more defi- 
nite than cerebrospinal irritation from any cause. 



CHAPTER XVII. 

ABSCESS, GANGRENE, AND CANCER OF THE LUNG. 
PULMONARY ATELECTASIS, (EDEMA, AND HYPO- 
STATIC CONGESTION. 

Abscess and Gangrene of the Lung. 

I consider these two affections together because the physical 
signs, exclusive of the sputa, do not differ materially in the two 
affections. In some cases there may be no physical signs at all, 
and the diagnosis is made from the character of sputa and from a 
knowledge of the etiology and symptomatology of the case. In 
other cases we find nothing more than a patch of coarse rales or a 
small area of solidification, over which distant bronchial breathing, 
with increased voice sound and fremitus, may be appreciated. 
Rarely there may be slight dulness on percussion, but as a rule the 
area is not sufficiently large or sufficiently superficial to produce 
this. One may find the signs of cavity (amphoric breathing, 
cracked-pot resonance, and gurgling rales), but this is unusual. 

Gangrene of the lung is not a common disease. The diagnosis 
usually rests altogether upon the smell and appearance of the sputa. 
In fetid bronchitis one may have sputa of equal foulness, but the 
odor is different. The finding of elastic tissue in the sputa proves 
the existence of something more than bronchitis. 

Pulmonary abscess, which, like gangrene, is a rare affection, is 
often simulated by the breaking of an empyema into the lung and 
the emptying of the pus through a bronchus. Large quantities of 
pus are expectorated in such a condition, and abscess of the lung is 
suggested, but the other physical signs are those of empyema and 
should be easily recognized as such. The finding of elastic fibres 
is the crucial point in the diagnosis of intrapulmonary abscess, 



358 PHYSICAL DIAGNOSIS. 

whether due to the tubercle bacillus or to other organisms. Tuber- 
culous abscess (cavity) is usually near the summit of the lung, and 
other varieties of abscess are near the base, but often there are 
no physical signs by which we can distinctly localize the process. 

Malignant Disease of the Lung, Pleura, or Chest Wall. 

In its earlier stages this affection is often mistaken for empy- 
ema or serous effusion in the pleural cavity, and indeed the physi- 
cal signs may be in part due to an accumulation of fluid secondary 
to the malignant growth within the lung. The rapid emaciation 
of the patient and the presence of a dark-brown bloody fluid in the 
pleural cavity, as determined by puncture, make us suspect malig- 
nant disease, but in sarcoma there is usually no emaciation until 
late in the course of the disease. The sputa rarely contain frag- 
ments of tissue whose structure can be recognized as characteristic 
of malignant disease. Secondary deposits in the supraclavicular 
glands may suggest the diagnosis. 

The thorax is usually somewhat asymmetrical. The affected 
side may be either contracted or distended according to the nature 
of the malignant growth within; occasionally it is not deformed 
at all. When the growth attacks only the lung tissue itself, leaving 
the bronchi and mediastinum free, we get signs like those of pleu- 
ral effusion (flatness, absent breathing, voice sounds, and tactile 
fremitus). 

If the disease begins in the bronchi, we may have a noisy dysp- 
noea from stenosis of a bronchus, and a weakening of the respiratory 
sounds normally to be heard over the trachea in front has several 
times been noted. Percussion dullness, if present, is usually over 
the upper portions of the chest, and may disappear and reappear 
or skip from place to place in a very irregular and confusing way. 

Signs and symptoms of pressure in the mediastinum due to sec- 
ondary involvement of the peribronchial glands may be present and 
may simulate aneurism, or the growth may press directly upon the 
brachial plexus, producing pain in the arm. 



v ATELECTASIS. 359 

Atelectasis. 

(a) Areas of atelectasis or collapse of pulmonary tissue are 
often present in connection with various pathological processes in 
the lung (such as tuberculosis or lobular pneumonia), but are usu- 
ally too small to give rise to any characteristic physical signs; 
nevertheless 

(b) In most normal individuals a certain degree of atelectasis 
of the margins of the lungs may be demonstrated in the following 
way : The position of the margins of the lungs in the axillae, in the 
back, or in the precordial region are marked out by percussion at the 
end of expiration. The patient is then directed to take ten full 
breaths, and the pulmonary outlines at the end of expiration are 
then percussed out a second time. The pulmonary resonance will 
now be found to extend nearly an inch beyond its former limits, 
owing to the distention of previously collapsed air vesicles. 

If one auscults the suspected areas during the deep breaths 
which are used to dispel the atelectasis, very fine rales are often 
to be heard at the end of expiration, disappearing after a few 
breaths in most cases, but sometimes audible as long as we choose 
to listen to them. These sounds, to which Abrams has given the 
name of "atelectatic crepitation,' 7 are in my experience especially 
frequent at the base of either axilla. The same writer has noticed 
an opacity to the x-rays over such atelectatic areas. 

Forcible percussion may be sufficient to distend small areas of 
collapsed lung, or at any rate to dispel the dulness previously pres- 
ent (see above, p. 136, the lung reflex). 

(c) When one of the large bronchi is compressed (as by an 
aneurism) or occluded by a foreign body, collapse of the corre- 
sponding area of lung may be shown by diminished motion of the 
affected side, dulness on percussion, and absence of breathing, voice 
sounds, and tactile fremitus. 

In new-born babies whose lungs do not fully expand at the time 
of birth, similar physical signs are present over the non-expanded 
lobes. The right lung is especially apt to be affected 

In the differential diagnosis of extensive pulmonary collapse, 



360 PHYSICAL DIAGNOSIS. 

the etiology, the suddenness of their onset, the absence of fever and 
of displacement of neighboring organs enable us to exclude pneu- 
monia and pleuritic effusion. In distinguishing small areas of 
solidification from similar areas of atelectasis, Abrams finds the 
" lung-reflex" (see page 136) of value. Atelectatic areas expand 
if the skin overlying them is irritated. Solidified areas show no 
change. 

(Edema of the Lungs. . 

In cardiac or renal disease one can often demonstrate that the 
lungs have been invaded by transuded serum as a part of the gen- 
eral dropsy. More rarely pulmonary oedema exists without much 
evidence of oedema in other organs or tissues. 

The only physical sign characteristic of this condition is the 
presence of fine moist rales in the dependent portions of the lungs ; 
that is, throughout their posterior surfaces when the patient has 
been for some time in a recumbent position ; or over the lower por- 
tions of the axillae and the back if the patient has not taken to 
his bed. 

The rales are always bilateral (unless the patient has been lying 
for a long time on one side), and the individual bubbles appear to 
be all of the same size, or nearly so, differing in this respect from 
those to be heard in bronchitis. No squeaking or groaning sounds 
are to be heard. The respiratory murmur is usually somewhat 
diminished in intensity. 

Dulness on percussion and modification of voice sounds are not 
present, unless hydrothorax or hypostatic pneumonia complicate 
the oedema. 

Hypostatic Pneumonia. 

In long, debilitating illness, such as typhoid fever, the alveoli 
of the dependent portions of the lungs may become so engorged 
with blood and alveolar cells as to be practically solidified. Under 
these conditions examination of the posterior portions of the lungs 
shows usually : 

(a) Slight dulness on percussion reaching usually from the 



HYPOSTATIC CONGESTION. 361 

base to a point about one-third way up the scapula. At the very 
base the dulness is less marked and becomes mixed with a shade of 
tympany. 

(b) Feeble or absent tactile fremitus. 

(c) Diminished or suppressed breathing and voice sounds. 

The right lung is apt to be more extensively affected than 
the left. 

Occasionally the breathing is tubular and the voice sounds are in- 
creased, making the physical signs identical with those of croupous 
pneumonia, but as a rule the bronchi are as much engorged as the 
alveoli to which they lead, and hence no breath sounds are pro- 
duced. 

Kales of oedema or of bronchitis may be present in the adjacent 
parts of the lungs. The fact that the dulness is less marked at the 
base of the lung than higher up helps to distinguish the condition 
from hydrothorax. 

The diagnosis is usually easy, owing to the presence of the un- 
derlying disease. Fever, pain, and cough such as characterize 
croupous pneumonia are usually absent. 



CHAPTEE XVIII. 

THE ABDOMEN IN GENERAL, THE BELLY WALLS, 
PERITONEUM, OMENTUM, AND MESENTERY. 

Examination of the Abdomen in General. 

Our methods are crude and inexact compared to those applica- 
ble to the chest. Auscultation is of practically no use. Inspec- 
tion is helpful in but few cases. Palpation, our mainstay, is often 
rendered almost impossible by thickness, muscular spasm, or ticklish - 
ness of the abdominal walls. Percussion is of great value in some 
cases, but yields no useful results in the majority. 

Technique. — The knack of abdominal examination, and especially 
that part of it whereby the skilled diagnostician gets his most val- 
ued information, is difficult even to demonstrate and almost impos- 
sible to describe. Hence the account of it in this and other books 
is very brief when compared with the space allotted to the methods 
of examining the chest. 1 

The table or bed on which the patient lies during most abdomi- 
nal examinations (excluding gynaecological work) should be at least 
three feet high, narrow, and firm. Most beds are too low, too 
wide, and too soft ; but, on the other hand, the patient must not be 
made uncomfortable by the hardness or coldness of the surface on 
which he lies. A comfortable pillow should be provided. 

1 1 have heard a physician in a leading American city say that when pal- 
pation of the spleen in typhoid fever was first introduced, there was but one 
physician in the city who had the knack, and that his colleagues were very 
sceptical about the possibility of accomplishing the feat at all. I have seen a 
similar uncertainty regarding the palpation of the normal but slightly dis- 
placed right kidney. 



THE ABDOMEN IN GENERAL. 363 

Inspection. — We need a tangential light, such as accentuates 
by shadows every unevenness of the surface. If the patient is ex- 
amined in the ordinary dorsal decubitus, the light from any single 
window, except one overhead, is satisfactory. If one inspects the 
abdomen with the patient upright, he should stand with his side to 
the light, not facing it. By inspection we seek information on : 

(a) The general contour of the abdomen. 

(b) The surface of the belly walls, especially the skin and the 
navek 

(c) Respiratory movements, their limitation or absence. 

(d) Peristaltic movements (gastric or intestinal in origin). 

(e) The presence of local prominence or (rarely) depression. 
Inspection of the Belly Wall. — 1. The surface of the belly wall is 

often searched most carefully for the rose spots of typhoid fever, 
which are hypersemic, very slightly elevated spots, about the diam- 
eter of a large pin head (2-4 mm.). They disappear on pressure. 
Pimples are usually larger, better defined at the edges, and more 
highly colored, contrasting with the very pale red of most rose 
spots. They are by no means confined to the belly and may be 
found exclusively on the back. Having been at the outset some- 
what sceptical of their value in diagnosis, I have become thoroughly 
convinced by greater experience and more careful examination. 
The spots are present in about three-fourths of all cases, and, while 
they also occur in any disease when the blood contains bacteria 
{e.g., sepsis), they are commonest in typhoid. 

2. Distended and tortuous veins on the abdomen are seen in dis- 
eases obstructing the portal circulation (especially cirrhotic liver) 
or the inferior cava (see Fig. 60). 

3. Striae, or linear markings on the skin of the abdomen, follow 
any long-standing trouble that stretches the skin — pregnancy, obes- 
ity, tumors, etc. They are red when first produced, but later 
turn white (linece albicantes). 

4. Scars of old wounds or operations may be of great diagnostic 
value in comatose or delirious cases. 

5. Projection or levelling of the normal depression at the navel 
is evidence of distention within the belly. 



364 PHYSICAL DIAGNOSIS. 

Respiratory movements of the belly walls are limited or cease in 
painful diseases within the peritoneum (peritonitis, lead colic) or 
when the diaphragm is pushed up by a large tumor, ascites, or mete- 
orism. 

Peristaltic waves creeping along beneath the belly walls are 
seen with chronic stenosis and obstruction at the pylorus or at some 
point in the colon and occasionally in thin but healthy persons. 

Local and general prominence will be discussed in connection 
with abdominal tumors (page 368). 

Palpation. 1 — With the patient on the back upon a suitable bed 
or table, 2 the head on a comfortable pillow, and the abdomen ex- 
posed, run the palm of the hand (warm) lightly over the whole sur- 
face, to accustom the muscles to its presence. Then try whether 
better relaxation of the belly walls is obtained when the patient's 
knees are drawn up. Some patients relax better in this position ; 
others when the legs are extended. 

If the muscles of the abdomen remain contracted and stiff even 
when the patient is comfortable and has become accustomed to the 
presence of the physician's hand, we may try to induce relaxation : 

(a) By getting the patient to take a series of deep breaths. 

(b) By diverting his attention through conversation or other- 
wise. 

If these means fail and it is important that we should thoroughly 
investigate the abdomen, we have left two further ways of produc- 
ing relaxation, viz. : 

(c) By putting the patient into a warm bath. 

(d) By anaesthesia (ether or chloroform). 

The movements of the physician's hand should never be sudden 
or rough. He should avoid digging into the skin with his nails or 
pressing strongly on a small spot with the finger-tips. If any spot 

1 Special methods of palpating a diseased kidney, spleen, or liver are de- 
scribed in the sections on those organs. 

2 It is essential that the physician as well as the patient should be comfort- 
able during an abdominal examination, else his attention is not wholly on his 
work. Hence the importance of a high, narrow bed, or table, so that the 
physician need not stretch or stoop to reach the patient. 



THE ABDOMEN IN GENERAL. 365 

be suspected to be tender, that should be palpated last, after going 
over the rest of the abdomen. If it is necessary to make deep 
pressure at any point, it is best to lay the fingers of the left hand 
loosely over the spot and then exert pressure upon them with the 
fingers of the right hand. The passive hand is more sensitive. To 
reach a deep spot, put the hands in this position over it, ask the 
patient to take a long breath, and, as the belly falls in expiration, 
follow it down with the hands. Then hold what you have gained, 
and with the next full expiration you may be able to get in still 
deeper, until after a series of deep breaths the desired spot is 
reached. Naturally this cannot be done if there is much tender- 
ness, but pure nervous spasm may sometimes be overcome in this 
way. 

To make use of the relaxation secured by a hot bath, we need 
an unusually long tub, so that the patient can lie almost flat when 
his knees are slightly drawn up. If he is doubled up with his 
knees and head in close proximity, nothing can be accomplished. 
The patient gets into the tub with the water comfortably warm, and 
its temperature is then raised to between 110° and 120° F. by pour- 
ing in very hot water. The greatest relaxation is usually attained 
after about ten minutes' immersion. 

This method is far less inconvenient than etherization and is 
especially valuable when the recti are well developed and form 
rounded, tumor-like masses as soon as ordinary palpation is at- 
tempted. If we suspect that a tumor-like mass may be one of the 
bellies of the rectus, it is well to grasp the mass with the hand and 
then ask the patient to raise his head. The mass will harden sud- 
denly if it is the rectus. 

What can be Felt Beneath the Normal Abdominal Walls. 

No part of the normal intestine, including the appendix, can, 
in my opinion, be felt through the abdominal walls. The same is 
true of the stomach, spleen, left kidney, pancreas, 1 bladder, and 

'Leube believes that in very thin subjects the head of the pancreas may 
occasionally be felt. 



366 PHYSICAL DIAGNOSIS. 

pelvic organs. The only normal abdominal organs that we can 
often feel are : 

1. The abdominal aorta. 

2. The spinal column, near and above the umbilicus. 

3. Part of the liver (occasionally, if the costal angle is sharp and 
the belly walls are thin and lax). 

4. The tip of the right kidney (in many young persons). 

5. Gurgling and splashing in the stomach or colon. 

The aorta is too deep to be felt at all in some persons, but, on 
the other hand, it is astonishing how close under the belly wall it is 
in others, i.e., in those whose dorsal spine projects sharply for- 
ward. In such persons the aorta may be almost taken in the hand, 
and its course, calibre, and motions are so startlingly evident that 
it is often mistakenly supposed to be the seat of an aneurism (see 
above, page 280), especially as a systolic murmur and thrill can be 
appreciated over it if a little pressure is exerted, so as to produce 
an artificial stenosis. 

Behind and beside the aorta we can sometimes feel the bodies of 
the vertebrae, and on them trace the division of the aorta into the 
common iliacs. 

The liver cannot be felt at all in the great majority of normal 
persons, but occasionally the costal angle is so sharp that a small 
portion of the organ is palpable in the epigastric region. 

Bimanually (see below, page 415) the tip of the normal right 
kidney may often be caught between the hands at the end of a 
long inspiration, especially in young, thin people with lax belly 
walls. 

If the stomach or colon contains fluids, the palpating hand often 
elicits sounds corresponding to the movement of these fluids. Their 
only importance in diagnosis will be mentioned on page 376. 

The ilio-psoas muscle can occasionally be felt deep in the iliac 
region. 

Very deceptive often are muscular bundles in the external 
oblique, which seem distinguishable as sausage-shaped tumors, and 
doubtless give rise to some of the legends about feeling the nor- 
mal appendix. 



THE ABDOMEN IN GENERAL. 



367 



Palpable Lesion of the Belly Walls. 

The occurrence of lesions, to be recognized mainly by inspection 
and percussion, has been discussed (page 363). Besides these we 
search for : 

1. Hernial^ epigastric or umbilical (see Fig. 179). The diagnosis 
rests on the presence of an impulse on coughing, with or without a 
reducible tumor. 

2. Separation of the Recti. — When the patient, lying on the 
back, lifts his head and shoulders, a longitudinal wedge bulges out 




Fig. 179.— Epigastric Hernia. 



along the median line of the belly from the gastric to the suprapu- 
bic region. 

3. Abscess of the abdominal walls usually represents a stitch ab- 
scess or the external vent of pus burrowing from the appendix, the 
pelvis, or the prevesical space. Bat in about one-third of the 
cases no such cause can be found. An infected hematoma due to 
trauma or without known cause explains some cases, and occasion- 
ally tuberculosis or actinomycosis occurs. The latter conditions 
are recognized by the microscopic examination of the pus and of the 
abscess wall. 

4. Sarcoma of the belly wall is rather rare, and can be recog- 
nized with certainty only by microscopic examination ; without this 
I have known it to be confused with lipoma and with tuberculosis. 



368 PHYSICAL DIAGNOSIS. 

5. Thickening or inflammation at the navel occurs in some cases 
of cancerous or tuberculous peritonitis. The diagnosis rests on the 
further evidence of cancer or tuberculosis within the peritoneal cav- 
ity and on the microscopic examination of a piece excised for the 
purpose. 

Palpation of the Spleen (see page 411). 

Palpation of the Liver (see page 386). 

Palpation of the Kidney (see page 415). 

Palpation of Abdominal Tumors. 

One should notice : Size, contour, consistency , mobility with.press- 
ure and icith respiration, tenderness, pulsation, peritoneal crepitus, 
adherence to the skin or to the abdominal wail, relationship to any 
abdominal organ (also dulness or resonance on percussion, see below, 
page 370). 

Most of these points need no comment. To ascertain whether 
the tumor involves the skin, one lifts up a fold of skin crossing the 
mass. If the skin dimples markedly over the tumor, i.e., fails to 
rise at that point while on all sides of the mass it can easily be 
picked up, the skin is adherent. Tumors in the abdominal wall 
can usually be gathered up along with the latter when we grasp a 
large fold with both hands. 

To determine the relationship of a tumor with the liver or spleen 
we note : 

(a) Whether a groove or interval can be made out, b}^ palpation 
or percussion, between the mass and either of those organs. 

(b) Whether its respiratory mobility is as great as theirs. 

(c) Whether there are other facts in the case suggestive of he- 
patic or splenic disease (jaundice, ascites, leuksemic blood). 

(d) The effect of inflation of the colon (see below). Tumors 
connected with the spleen are forced forward and do not become 
resonant when the colon is inflated. 

To determine the degree of respiratory mobility, hold the fingers 
of one hand in contact with the lower edge of the mass and allow 
them to descend with it while the patient takes a full breath. To 



THE ABDOMEN IN GENERAL. 369 

make sure that an actual descent occurs, one must sight the mass 
(and the hand) against some motionless object in the room beyond, 
else one may be deceived by the movement of the abdominal walls 
over the tumor, while the tumor itself remains motionless or nearly 
so. Tumors connected with the liver or spleen move about two 
inches with a forced inspiration. Kidney tumors move less, seldom 
as much as an inch. Pancreatic and retroperitoneal tumors have 
scarcely any mobility. Those connected with the intestine vary 
considerably in respiratory mobility, according to the presence and 
degree of adherence to other parts, but their excursion is rarely an 
inch. 

Peritoneal crepitus is a grating, rubbing sensation experienced 
on light palpation, and due — supposedly — to the presence of a 
plastic, peritoneal exudate similar to that which produces the 
friction sounds in pericarditis. Over an enlarged spleen {e.g., in 
leukaemia) peritoneal crepitus may be due to local perisplenitis, and 
in perigastritis, perihepatitis, and perienteritis similar crepitus 
occurs. 

Dipping refers to a sudden displacement of the abdominal wall 
and whatever lies close beneath it, by a swift poke of the finger 
tips, which may succeed thereby in touching a solid organ or tumor 
which gentle, gradual palpation misses. Thus one may reach and 
mark out an enlarged liver through a layer of ascites which would 
prevent ordinary palpation. 

Percussion. — Abdominal percussion is much easier than tho- 
racic. A lighter blow is used, and the distinction between dulness 
and tympany is easy. It is of value chiefly to determine the pres- 
ence of fluid free in the peritoneal cavity, and to ascertain whether 
a tumor is due to or covered by gaseous distention. 

(a) Free fluid (ascites, peritonitis, haemoperitoneum, ruptured 
cyst) gravitates to the flanks and suprapubic region, while the in- 
testines float up and occupy the epigastric and umbilical space. 
Hence there is dulness in the flanks and over the pubes, with reso- 
nance in the epigastric and umbilical regions. But the crucial and 
ever-necessary test is the shifting of this area of dulness whea the 
patient turns on his side ; then the uppermost flank should become 
24 



370 PHYSICAL DIAGNOSIS. 

resonant and the lower half of the belly — including part of the 
umbilical region — dull. Without this test the mere marking out of 
dull areas in the flanks is not conclusive evidence of free fluid there. 
Still less reliable is the "fluctuation wave," which can be trans- 
mitted as an impulse palpable to the hand laid flat on one flank, 
by sharply snapping the other flank. Similar impulses can be trans- 
mitted through the fat of the belly wall, despite all efforts to check 
them by pressure upon the latter. 

(b) Percussion is our final test in the diagnostic procedure that 
begins with inflation of the colon. Air is forced into the rectum 
with an ordinary Davidson syringe, and, as the calon becomes 
prominent and hyperresonant, we note whether its tympany covers 
up the tumor-mass under investigation or whether the mass lies an- 
terior to and remains dull over the inflated colon. Kidney tumors 
lie behind the inflated colon ; splenic tumors remain dull in front 
of it. 

Auscultatory percussion, for identification or demarkation of ab- 
dominal tumors and organs, has never been successful in my hands 
nor in those of most of the observers in whose results I have confi- 
dence. Hence I omit further description of it. 

Percussion of the stomach and spleen (see below, pages 378 and 
410). 

Percussion of Traube 's semilunar tympanitic space (the small 
area bounded on the right by the splenic and on the left by the he- 
patic dulness, above by the free edge of the left lung, and below by 
the lower edge of the ribs) is, in my experience, of very little value 
in diagnosis. This tympanitic area is obliterated in many pleuritic 
effusions (not in all), but many other causes (full stomach or gut, 
obese omentum) may produce similar dulness. 



Diseases of the Peritoneum. 

1. Peritonitis — local or general. 

2. Ascites. 

3. Cancer and tuberculosis. 



THE ABDOMEN IN GENERAL. 371 



I. Peritonitis. 

1. Local peritonitis gives evidence of its presence by (a) pain, 
(b) tenderness, (c) muscular spasm, (d) tumor, and (<?) constitu- 
tional manifestations. 

The pain may be at first diffuse, later localizing itself at the site 
of the lesion ; or it may be felt first where the peritonitis begins and 
spread with the lesion if the general peritoneal cavity become in- 
volved. The character and intensity of the pain vary greatly. 

Tenderness is the important sign in diagnosis, and helps us to 
exclude the various colics and other causes of pain which are often 
relieved by pressure. 

Local muscular spasm of the belly muscles to guard the tender 
lesion beneath is of great value in pointing our attention to the spot 
affected, though the muscles may be so rigid as to prevent palpa- 
tion through them. [Psoas spasm is described in the section on 
appendicitis, see page 400.] 

The tumor is apt to consist of intestine or other organs matted 
together by adhesions about the site of the process. 

The constitutional manifestations are those of infection, viz., 
fever, leucocytosis, anorexia, constipation, often albuminuria and 
albumosuria. 

The commonest causes of local peritonitis are : 

1. Appendicitis. 

2. Pus tube. 

3. Gall-bladder inflammation. 

Less common is cancer or ulcer of the stomach or intestine. 

2. General Peritonitis. — The belly may be generally swollen and 
tympanitic or retracted and hard. General tenderness is the most 
important sign. In advanced cases free fluid in the flanks may be 
demonstrated, as explained on page 369. Faeces and even gas cease 
to move, as the intestines are paralyzed. Vomiting is the rule, and 
soon becomes very foul (stercoraceous). There is fever, with a 
rapid and very weak pulse. The mind is clear, alert. The facial 
expression is not peculiar and may be normal. If there is persis- 



372 



PHYSICAL DIAGNOSIS. 



tent vomiting the facies of that condition appears, viz., a drawn, 
pinched, anxious look, with dark circles under the eyes. The nau- 
sea and the rapid loss of fluid "by vomiting account for these ap- 
pearances. 

The leucocyte count is generally elevated, but in the most 
virulent cases remains normal or sub- 
normal. 

II. Ascites. 



The causes are : 

(1) Portal stasis, usually from cir- 
rhosis of the liver. 

(2) Dropsy, from cardiac or renal 
disease. 

(3) Tuberculous peritonitis. 

(4) Anaemia. 

(5) Cancer of the peritoneum. 

(6) Various unknown lesions. 
The methods of diagnosis of ascites 

have been explained above. The diag- 
nosis of its cause depends on the his- 
tory and the general physical exami- 
The contour of the belly is often that pictured in Fig. 




fig. 



180.— Characteristic Shape of 
Belly In Ascites. 



nation. 
180. 



III. Cancer and Tuberculosis of the Peritoneum. 



In connection with cancer or tuberculosis of some abdominal or 
pelvic organ, the disease may become spread throughout the perito- 
neum with deposits in the omentum and mesentery. The signs 
are : 1. Tumor masses scattered here and there, sometimes at the 
navel. 2. Ascites. 3. Emaciation and anaemia. 

The diagnosis of cancer depends on the recognition of multiple, 
hard, nodular tumors in the abdomen of a patient known to have 
cancer of some abdominal organ. 

Somewhat similar masses, usually due to loops of intestine 



i 



THE ABDOMEN IN GENERAL. 373 

matted together by adhesions, may be felt in tuberculous peritonitis, 
but here they are larger, fewer, and not so hard. Cancer appears 
in late life, tuberculous peritonitis usually in early life. The ema- 
ciation and anaemia are less marked in tuberculosis, and fever is 
more marked. The history or present evidence of tuberculosis else- 
where — lung, pleura, glands, pelvis, testis — favors the diagnosis of 
tuberculous peritonitis. If fever is not marked the tuberculin test 
may be of value in diagnosis. 

The Mesentery. 

1. Enlarged glands — tuberculous, cancerous, or as part of 
Hodgkin's disease — can occasionally be felt in very thin patients. 
Their recognition as glands would depend on more obvious evidence 
of their cause in other parts of the body. 

2. Mesenteric thrombosis produces all the signs of intestinal ob- 
struction (see below, page 401), from which it can rarely if ever be 
distinguished without operation or autopsy. 



CHAPTER XIX. 

THE STOMACH, LIVER, AND PANCREAS. 
The Stomach. 

The best methods of examining the stomach are: 

1. Inspection and palpation of the epigastrium and the neigh- 
boring portions of the abdomen. 

2 Estimation of the size and position of the organ after dis- 
tending it with air or water. 

3. Examination of the stomach contents : (a) fasting ; (b) after 
a test meal. 

By combining the results of these three methods of examination 
with the results of our general examination of the body — emacia- 
tion, anaemia, etc.— and with the data obtained by a careful history, 
we obtain all the information about the stomach which it is possible 
for us to make use of at the present time. 

1. Inspection and Palpation of the Epigastrium. 

(a) Tenderness. — The normal stomach cannot be seen or felt, 
nor can anything certain be learned in regard to it by percussion or 
auscultation. Tenderness in the epigastrium is so common that we 
can attach no significance to it unless it is extreme and sharply lo- 
calized in a small area. Extreme localized tenderness is of a cer- 
tain amount of value in connection with the diagnosis of gastric 
ulcer, but is by no means pathognomonic of it. In a small propor- 
tion of cases tenderness in the back (lower dorsal or upper lumbar 
region) can be elicited in cases of gastric ulcer. 



THE STOMACH, LIVER, AND PANCREAS. 



375 



(b) A tumor in the epigastrium (see Fig. 181) is of far greater 
importance than any other local evidence. If it occurs in an emaci- 
ated and anaemic person past middle life, is hard and nodular, and 
does not disappear after catharsis, it is almost invariably due to 
cancer of the stomach. In a young person such a tumor may be 
due to a mass of adhesions about a gastric; ulcer. Tumors of the 
pancreas much less often reach the surface in this region ; tumors 
of the liver are generally larger, and their connection with this or- 




Fig. 181.— Epigastric Tumor in Gastric Cancer. 



gan can generally be demonstrated by percussion, palpation, and 
by their greater respiratory mobility when compared with gastric 
cancer. 

Epigastric hernia usually shows an impulse on coughing, is soft 
and doughy in feel, and presents none of the other symptoms and 
signs of gastric cancer. 

Tubercular deposits in the omentum are almost always associ- 
ated with ascites, fever, and other evidences of tuberculosis either 
in the examination of other organs or in the history. 

(c) Visible gastric peristalsis means stenosis of the pylorus (can- 
cer, cicatrix, adhesions, simple thickening, or muscular spasm). 
The contraction wave passes from left to right across the epigas- 
trium, and is seen by means of the shadow cast by a tangential 
light with the patient in a recumbent position. If the peristalsis 



376 



PHYSICAL DIAGNOSIS. 



stops it can sometimes be reexcited by briskly snapping the epigas- 
tric region with the finger. 

(d) The normal splash sound can usually be heard if sudden, 
quick pressure is made in the epigastrium within three hoars after 
a meal. If splashing can be elicited more than three hours after a 

meal, and especially if it is 
present before breakfast, it is 
evidence of gastric stasis and 
usually of dilatation. 

(e) Hypogastric bulging due 
to dilated stomach is occasion- 
ally seen in cases of marked 
dilatation when the patient 
stands up, and is examined in 
profile (see Fig. 182). 




Fig. 182.— Outline of Abdomen in Dilatation of 
the Stomach. 



2. Estimation of the Size, Posi- 
tion, Secretory and Motor 
Power of the Stomach. 

Whenever we cannot arrive 
at a satisfactory diagnosis by 
means of the above methods of 
external examination when 
taken in connection with the 
history and the general condi- 
tion of nutrition, we must undertake a more direct investigation of 
the organ, which begins with («) the passage of the stomach tube. 
The standard red rubber tube generally in use in this country 
comes in two sizes. Personally I prefer the larger, with a lateral 
as well as a terminal opening at the lower end, although the smaller 
size produces somewhat less discomfort. The patient should be 
covered by a rubber sheet and the clothing removed from his abdo- 
men. So prepared, he should sit in a straight-backed, wooden 
chair, with a good-sized foot-tub between his feet and a towel in 



THE STOMACH, LIVER, AND PANCREAS. 377 

his hand ready to wipe away the profuse secretions of the mouth 
and pharynx. He should then be warned that the process of pass- 
ing a tube, although entirely free from danger, is very disagreeable, 
both on account of the nausea which it produces and because it 
often seems to the patient as if he were choking and could not get 
his breath. This, in fact, is not the case, and if the patient will 
persist in drawing long, deep breaths throughout the process of 
passing a tube, the worst of it is over in twenty seconds. 

The tube is moistened with water and pushed straight down 
through the pharynx without any attempt to direct it, beyond keep- 
ing the median line. There is no danger of entering the trachea 
and no use in trying to avoid it. On its way down the tube is ar- 
rested now and then by muscular spasm of the oesophagus, but after 
a few seconds the spasm relaxes and allows us to push the tube on 
until the twenty-two-inch mark reaches the teeth. The lower end 
of the tube is then in the stomach, 1 and we are ready to extract the 
gastric contents (in case a test meal has been previously given), to 
wash out the organ, or to distend it with air or water. 

(b) Extracting the Gastric Contents. — One hour after a test 
meal 2 the tube is passed and the patient is then asked to lean for- 
ward, press with his hands upon his stomach, and strain down as 
if he were going to have a movement of the bowels. In most cases 
this suffices to force the gastric contents out through the tube and 
into a basin, which is held ready to receive it. If the gastric con- 
tents cannot be extracted either by these manoeuvres or by moving 
the tube against the pharynx so as to excite nausea, we should make 
sure first that the eye of the tube is not plugged. This may be 
ascertained by disconnecting the funnel and blowing through the 
tube, which usually suffices to discharge any obstacle from the eye 
of the tube. If still the gastric contents do not flow out, we may 
use suction by connecting a Politzer air-bag with the end of the 
tube in place of the funnel. 

1 Unless there is gastric dilatation or gastroptosis ; then the tube must be 
pushed in several inches farther, the distance depending on the position of the 
lower gastric border, as determined in previous examinations. 

2 A slice of bread and a glass and a half of water is a good test meal. 



378 PHYSICAL DIAGNOSIS. 

For the analysis of the contents so obtained, see below, page 
379. 

(c) Distending the Stomach. — We may use either air or water. 
The first is more comfortable, the second rather more accurate. To 
distend the stomach with air, disconnect the funnel and attach a 
Davidson syringe. Then have the patient — still with the tube in 
his stomach — lie down upon a bed with the abdomen exposed, and 
pump air rapidly in with the Davidson syringe. The rapid entrance 
of air causes a reflex closure of the pylorus and allows us to distend 
the stomach. While an assistant pumps in the air, Ave inspect and 
percuss the epigastric region, which soon begins to bulge out and 
assume on percussion a tympanitic note differing clearly in pitch 
and quality from that obtained in other portions of the abdomen. 
After a certain amount of air has been pumped in, the lower border 
of the stomach (as shown by percussion) ceases to descend, and 
about this time the patient begins either to complain of pain or to 
belch up wind around the tube, showing that the organ is fully dis- 
tended. We then mark upon the abdominal wall the position of the 
lower border of the stomach, and if possible of the upper, which 
can usually be obtained by percussion. 

Position of the Normal Stomach. — The lower border of the nor- 
mal stomach after air distention does not descend below the level 
of the umbilicus ; hence any stomach whose lower border descends 
lower than this should be considered dilated, provided that the 
upper border is approximately in the normal situation. If the up- 
per border is lowered as much as the fundus, we are probably deal- 
ing with a case of gastroptosis or dropping of the whole organ. 

To distend the stomach with ivater, we simply pour it in 
through the funnel until the patient complains of decided discom- 
fort and fulness. We then rapidly lower the funnel so that it will 
empty into a large foot-tub on the floor, allow the water to siphon 
out, and measure the amount so obtained. The normal stomach 
will hold about 1,500 c.c. (or three pints). Anything over this 
amount is pathological. A difficulty of the method of distention 
by water is that it is sometimes impossible to get out of the stom- 
ach all of the water that we have put into it, whereas with disten- 



THE STOMACH, LIVER, AND PANCREAS. 379 

tion with air there is no difficulty in forcing out the air through 
and around the tube by pressure on the epigastrium. 

(d) Washing the Stomach {Lavage). — Though not of much use 
in diagnosis, this procedure may be briefly mentioned here. After 
introducing the tube as above described, about a pint of water is 
poured in through the funnel, and, just before the water disappears in 
the vortex of the funnel, the latter is rapidly lowered so as to empty 
by siphonage into a vessel on the floor. This process is repeated 
until food and mucus cease to come out and the water runs clear. 

To remove the tube at the end of any of the procedures just de- 
scribed, we have only to pinch it tightly just outside of the pa- 
tient's teeth and pull it rapidly out. 

3. Examination of Gastric Contents. 

1. The contents of the fasting stomach are best obtained by pass- 
ing the tube before breakfast, and should consist of no more than a 
few cubic centimetres of clear fluid containing free hydrochloric acid. 
If any food is present, gastric stasis is proven. If more than 50 
c.c. of fluid without food are present, hypersecretion is indicated. 

2. Gastric Contents after a Test Meal. — -The best test meal is 
that of Ewald, and consists of a slice of bread (or its equivalent in 
crackers or cereal) with a glass and a half of water. After this 
meal not more than 100 c.c. should be found in the stomach at the 
end of an hour. Occasionally the stomach has emptied itself even 
within the hour, and we have then to reduce the period. 

After extracting the gastric contents as above described and 
noting the quantity, we should investigate also their color, odor, 
and general appearance, (a) Small streaks of blood are of no con- 
sequence. Considerable quantities of blood (fresh) suggest ulcer. 
Small quantities of dark-brown substance resembling blood should 
be investigated by the haemin test. If this is positive, gastric can- 
cer is suggested. 

The hcemin test is best performed as follows : Evaporate a small 
quantity of the suspected material to dryness on a glass slide ; next 
grind it up with an equal quantity of common salt, using the end 






380 PHYSICAL DIAGNOSIS. 

of a glass rod and thoroughly mixing the two substances ; add two 
drops of glacial acetic acid, and heat very gently but not quite to the 
point of dryness. When cool, examine with a high-power dry lens. 
Hsemin crystals are elongated, rhombic, and dark brown in color. 

(b) For acetic and butyric acids we test merely by our sense of 
smell. Whenever stasis or fermentation has occurred, we are apt 
to get a characteristic odor of these acids mingled with that of yeast. 

(c) The general appearance of the contents tells us little that is 
important. In cases of marked dilatation they often separate into 
three layers — the upper frothy, the middle a thin, turbid liquid, 
and the lower a flocculent sediment of partially digested food. 

Mucus is not of any considerable clinical significance unless it 
is so abundant that the whole stomach contents will slide in one 
lump from one beaker to another. 

When absolutely no digestion has taken place, as in the rare 
cases of achylia gastrica, the contents consist simply of unaltered 
bread and water. 

Chemical Tests of Gastric Contents. 

1. Dip a piece of blue litmus in the contents ; if no reddening 
occurs, no further tests need be made. 

2. If the contents are acid to litmus, test with Gunzburg' 's re- 
agent (phloroglucin, 2 gm. ; vanillin, 1 gm. ; alcohol, 30 gm.), by 
mixing two drops of it with an equal amount of gastric contents (un- 
filtered) upon a white porcelain plate or dish, and evaporating slowly 
over a flame. 1 If free HC1 is present, a bright rose pink appears. 
In the absence of free HC1, the color is a dirty yellowish-brown. 

If this test is positive, we need make no further tests except the 
following : 

Quantitative Estimation of Free HCl and of Total Acidity. 

To 10 c.c. of unfiltered gastric contents add four drops (about) 
of Topfer's reagent (dimethyl-amido-azo-benzol : 0.5 per cent alco- 

1 The same test may be performed on a glass slide which is subsequently 
put upon a piece of white paper to bring out the color. 



THE STOMACH, LIVER, AND PANCREAS. 381 

holic solution) in a beaker; a carmine-red color results. Fill a 
graduated burette with decinormal NaOH solution, and let it run 
out into the beaker, a few drops at a time, until the carmine-red 
color disappears. While titrating stir the mixture constantly with 
a glass rod. Note the number of cubic centimetres of NaOH that 
have run out. 1 

To estimate the quantity of free HC1, multiply the number of 
cubic centimetres of NaOH used in the titration by 0.0365; the 
result is the percentage of free HC1. Normal free HC1 varies from 
0.07 to 0.2 per cent, or from 2 to 6 c.c. of decinormal NaOH for 10 
c.c. of gastric contents. 

The estimation of combined HC1 and of the acid salts is seldom 
of importance. 

Total acidity is determined by adding to the same beaker of 
contents in which the free HC1 has just been neutralized two or 
three drops of a one-per-cent solution (alcoholic) of phenolphthalein, 
and continuing the titration with the NaOH solution (and constant 
stirring) until a permanent red color appears. By mutiplying the 
number of cubic centimetres of NaOH used from the beginning of 
the first titration up to the point when the red color reappears by 
0.0365, we obtain a figure i presenting the percentage of total acid- 
ity. The normal range of total acidity is from 0.15 to 0.3 per cent, 
and we usually find that we have used from 4 to 8 c.c. of the NaOH 
solution in the process of neutralizing 10 c.c. of gastric contents. 

Lactic acid is to be tested for only ivhen HCl is absent. The 
test must be made at once, since lactic acid soon develops in stom- 
ach contents which are kept in a warm place. To perform the test, 
we dilute a solution of FeCl (strong aqueous) with water until a 
faint yellow color barely remains. Then fill the concavities of two 
test tubes with this solution, using one for comparison. If, on 

1 An ordinary medicine-dropper may be substituted for the burette if we 
get an apothecary to mark with a file upon it the point to which a (previously 
measured) cubic centimetre of water rises when sucked into the dropper. 
The half-centimetre point can be similarly marked. Decinormal NaOH solu- 
tion is then sucked into the dropper and expelled, one-half centimetre at a 
time, into the beaker containing the Topfer's reagent and gastric contents. 



382 PHYSICAL DIAGNOSIS. 

adding a few drops of stomach contents to the other, a considerable 
intensiii cation of the yellow color occurs, lactic acid is almost cer- 
tainly present. A negative test rules out lactic acid. 

The sediment need not be examined. It is true that sarcinse and 
various bacteria (Boas-Oppler bacillus and others) are often found 
in cases of gastric stasis, but they add little if anything to the other 
evidence of stasis more easily obtained — i.e., the S} r mptoms men- 
tioned on page 384, the presence of splashing more than four hours 
after a meal, the evidence of dilatation or gastroptosis as given 
above, and the rinding of organic acids. 

4. Incidence and Diagnosis of Gastric Diseases. 

In the wards of the Massachusetts General Hospital the number 
of cases apparently of gastric disease treated between 1870 and 1905 
was as follows : 

Cancer. 403 

Ulcer 536 

Dilatation : 170 

Dyspepsia 1 1,002 

Total 2,111 

The data at our disposal are as follows : 

1. The history. 

2. The local and external examination of the epigastric region. 

3. The estimation of the size and motor power of the stomach. 

4. The examination of the gastric contents. 

(a) In advanced cancer of the stomach we have pain, emaciation, 
anaemia, symptoms of fermentation (see page 384), often dilatation 
and motor insufficiency due to pyloric stenosis, absence of HC1 in 
the gastric contents (often), and in many cases the presence of 
digested blood ("coffee grounds") in what is vomited or washed 
out of the stomach. But without the presence of an epigastric 
tumor all of these facts are insufficient for diagnosis. Even the 

1 I.e., cases of painful digestion including anomalies of motion, sensation, 
secretion, "gastritis" and "gastric catarrh," but without evidence of ulcer, 
cancer, or dilatation. 



THE STOMACH, LIVER, AND PANCREAS. 383 

tumor itself may deceive us, as the adhesions around a gastric ulcer 
may present a similar mass to the palpating hand. 

The age of the patient is of great importance, especially if dur- 
ing the earlier decades of life he has been totally free from gastric 
symptoms. Any type of dyspepsia, any sort of genuine gastric 
trouble, 1 occurring in a person over forty who has never had any 
such trouble before, is strongly suggestive of cancer. 

(b) Gastric ulcer gives us usually the symptoms of hyperacid- 
ity (see next paragraph) with a demonstrable excess of HC1 in the 
gastric contents and a more or less characteristic history ; but with- 
out the occurrence of hemorrhage with the vomiting of bright blood 
and perhaps tarry stools (melsena), diagnosis is never certain. 
Since gastric ulcer often leads to cicatricial stenosis at or near the 
pylorus, its symptoms are frequently complicated by those of gas- 
tric dilatation and stasis. 

(c) Hyperacidity (or, more strictly, hyperchlorhydria) gives us 
usually painful digestion, with a good appetite and a clean tongue. 
Pain may come soon after a meal, and in such cases it is apt to be 
excited especially by eating meat, but it is oftener felt when the 
stomach is quite empty — e.g., in the night or before a meal. It is 
prone to occur in chlorotic or neurotic persons or during periods of 
special stress and worry. It frequently leads to gastric ulcer. 

(d) Hypoacidity (hypochlorhydria) is not a disease, but a 
symptom occurring temporarily or for a longer period in connection 
with various stomach troubles (dilatation, "catarrh," nervous dys- 
pepsia), as well as in many conditions entailing general debility 
with stomach symptoms. Hypoacidity is often associated with 
stasis and fermentation. It is recognized, of course, by the chem- 
ical tests described above. 

(e) Gastric dilatation, when considerable, is almost always sec- 
ondary to pyloric obstruction (due to cancer, cicatrix, or adhesions) . 
Symptoms suggesting it are the vomiting at one time of a large 
quantity — a quart or more — of stomach contents, often containing 
fragments of food eaten more than four hours previously. Such 

1 We must be careful to exclude angina pectoris as well as gall stones and 
their effects. 



384 PHYSICAL DIAGNOSIS. 

attacks of vomiting occur usually not after every meal, but at 
longer intervals. It is to be positively diagnosed by passing a tube 
and distending the stomach with air or water. 

(/) Gastric stasis occurs with more or less constancy in almost 
every disease of the stomach and in many general constitutional 
diseases (tuberculosis, anaemia, general debility). It constitutes 
what is usually referred to by patients as " indigestion," " dyspep- 
sia," or "sour stomach." Fermentation of stomach contents too 
long retained is the essential point. This results in a sense of 
weight and pressure in the epigastrium, eructations of gas and of 
sour or burning fluids, loss of appetite, nausea, and vomiting. The 
tongue is generally furred and the bowels are constipated. Head- 
ache, vertigo, and depression of spirits often accompany it. 

The Liver. 

The Massachusetts General Hospital records (1870-1905) show 
the following figures bearing on the incidence of diseases of the 
liver : 

Passive congestion 1,288 

Portal cirrhosis 234 

Biliary cirrhosis (Hanot's) 

Cancer of the liver 184 

Sarcoma of the liver 2 

Abscess of the liver 51 

Leukemic infiltration 46 

Pseudolenkaemic infiltration 10 

Amyloid infiltration 9 

Fatty infiltration 6 

Hydatid cyst 8 

Syphilis 8 

" Simple cyst " 6 

Actinom} r cosis 3 

Acute yellow atrophy 2 

Tuberculosis 1 

Total 1,858 



THE STOMACH, LIVER, AND PANCREAS. 385 

Diseases of the Gall Bladder and Bile Ducts. 

Gall stones 457 

Acute cholecystitis 110 

Catarrhal jaundice 125 

Cholangitis 9 

Total 701 

The evidences of liver disease are two classes, local and general. 

Local signs include : (a) Pain and tenderness in the hepatic re- 
gion. (&) Enlargement of the organ, symmetrical or irregular, (c) 
Atrophy of the organ. 

The general signs which assist in the diagnosis of liver disease 
are: (a) Portal obstruction, (b) Jaundice, including changes in 
the color of the skin, mucous membranes, and excretions, (c) Loss 
of flesh and strength, (d) Evidences of infection (fever, leueocy- 
tosis, chills, sweats, anorexia), (e) Cerebral symptoms (headache, 
vomiting, depression, delirium, convulsions, coma). 

The various attempts to test the liver functions by chemical 
examination of urine and faeces have not as yet been successful ; 
hence all diagnoses of liver disease must be built up of the above 
eight groups of data. 

(a) Hepatic Pain. 

This forms little or no part of many cases of liver disease, since 
it occurs only ivhen the capsule is stretched or its nerves are involved 
in a perihepatitis. Many cases of hepatic abscess, for example, run 
their course without pain or become painful only when the pus bur- 
rows to the surface and stretches the capsule. Besides this capsule 
pain in liver disease, we have shoulder pain referred to the region of 
the right scapula, less often to other parts of the back. Capsule pain 
is most noticeable in cancer of the liver; shoulder pain in abscess. 

Tenderness is present in the same cases which are painful, i.e., 
those in which there is perihepatitis or stretching of the capsule 
by rapidly increasing tension from within. The latter condition is 
commonest in passive congestion, but is not characteristic of any 
single disease. 
25 



386 PHYSICAL DIAGNOSIS. 



(&) Enlargement of the Liver, 

Tumors behind the liver, pushing it forward and down, are of* 
ten overlooked, because they bring the liver so prominently into the 
foreground and fasten our attention on what is mistaken for an en- 
largement of the organ. Wherever the cause of a supposed enlarge- 
ment of the liver is not obvious, retroperitoneal sarcoma or some 
other deep-seated tumor should be suspected. 

I have already alluded to the possibility of mistaking the en- 
larged liver for empyema, and vice versa (see above, page 352). 

We are sure of an increase in the size of the liver only when we 
can feel its edge below the ribs and can determine by percussion 
that its upper border is not depressed. 1 To feel the edge of the 
liver, hook the fingers of both hands around the margin of the right 
ribs and ask the patient to take a deep breath. At the height of 
inspiration an edge may be felt to descend against the fingers and 
to push its way beneath them. Unless an edge, either sharp or 
rounded, is felt, one cannot be sure of hepatic enlargement, for per- 
cussion of the lower edge of the liver is notoriously unreliable 
Dulness below the costal margin is frequently found in cases with- 
out hepatic enlargement, and should never be relied on unless the 
liver can be felt. 

The long, smooth edge of the liver descending one to two 
inches with full inspiration is rarely mistaken for anything else, 
but if the edge is irregular and the surface nodular (see below) 
it may be hard to distinguish liver from stomach or possibly 
kidne}^. 

If ascites is present, the presence and dimensions of an enlarged 
liver beneath the fluid can sometimes be made out by dipinng (see 
above, page 369). If this is impossible, the ascites may be tapped, 
after which it is usually easy to feel any enlargement that is pres- 
ent, as the belly walls are very flaccid. 

1 A normal liver may be pushed down by air, water, or solid tumors in the 
lung and pleura, so as to be palpable below the ribs ; but the evidence of a 
cause and the low position of the upper border usually make diagnosis easy. 



THE STOMACH, LIVER, AND PANCREAS. 387 

The causes of hepatic enlargement (in adults 1 ), arranged ap- 
proximately in the order of frequency, are : 

1. Passive congestion (later stages of uncompensated heart dis- 
ease). 

2. Obstructive jaundice (from any cause). 

3. Cirrhosis. 

4. Fatty liver, including "infiltration" and "degeneration." 

5. Malignant disease. 

6. Syphilis of the liver (congenital or acquired). 

7. Abscess of the liver. 

8. Leukaemia and pseudoleukemia. 

9. Cholangitis. 

10. Amyloid. 

11. Hydatid cysts. 

The largest livers are found in malignant disease, biliary cir- 
rhosis, and abscess. 

In jussive congestion the liver is very tender, and the presence of 
uncompensated heart disease 2 usually makes the diagnosis easy. 
The surface of the organ is smooth and firm. 

In cirrhosis a distinction must be drawn between (a) latent or 
compensated cases, wholly without symptoms, and (&) uncompen- 
sated cases, in which diagnosis depends on the chronic enlargement 
without any considerable increase under observation, associated 
with evidence of portal or biliary obstruction (or both) and without 
much pain or irregularity of the liver. Eighty per cent of the two 
hundred and thirty-four cases recorded at the Massachusetts Gen- 
eral Hospital showed enlargement, and only twelve per cent showed 
pain (rf. Malignant Disease, below). 

The fatty liver is soft and smooth in feel. The presence of 
phthisis or alcoholism makes us suspect this diagnosis, which de- 
pends largely on excluding other causes of enlargement. 

Malignant disease of the liver (cancer or sarcoma) is usually sec- 

1 In infants rickets, anremia, and gastro-intestinal disturbances are often 
associated with enlarged liver, though the splenic enlargement is usually 
much greater in such cases. 

- Either primary or resulting from chronic bronchitis and emphysema. 



388 PHYSICAL DIAGNOSIS. 

ondary to new growth elsewhere. The liver grows rapidly under 
observation, is usually painful (80 per cent of 168 Massachusetts 
Hospital cases) and nodular. Jaundice and irregular fever are 
present in over one-half of the cases (54 and 62 per cent respec- 
tively), and the loss of flesh and strength is marked. 

Obstructive jaundice (due to stone, stricture, catarrh, or tumor 
of the bile ducts, or to any other cause) often produces an enlarged 
liver. Diagnosis depends on the evidence of a cause for the ob- 
struction and the absence of hepatic nodules, pain, or a rapid in- 
crease in the size of the organ. 

Syphilitic liver may be distinguishable from cirrhosis or from 
malignant disease only by the therapeutic test. The history or 
present evidences of alcoholism or of syphilis are important factors 
in diagnosis, but, since syphilis may simulate the nodular liver of 
malignant disease or the general enlargement and portal stasis of 
cirrhosis, it is essential to give antisyphilitic treatment in all doubtful 
cases of liver disease. 

Abscess of the liver produces enlargement, pain, fever, leucocy- 
tosis, and chills in typical cases, but any of these symptoms may 
be absent and diagnosis is often difficult. The presence of a possi- 
ble cause (amoebic dysentery, appendicitis) is important evidence. 
The enlargement is more apt to be upward and to the right than in 
other liver diseases, since the pus usually starts in the right lobe 
and burrows upward. Hence many cases are mistaken for empyema 
(see above, page 352). Should fluctuation appear externally the 
diagnosis is usually obvious, but in many cases this does not oc- 
cur. 

Soft new growths and syphilis may be almost indistinguishable 
from abscess by local signs, but jaundice is much commoner in ma- 
lignant disease and the liver of syphilis is often irregular. The 
history is of value. 

Suppurative cholangitis or pylephlebitis gives us practically the 
same symptoms as abscess, but the spleen is enlarged in about one- 
third of the cases. 

Amyloid liver is recognized by the presence of an appropriate 
cause (chronic suppuration or syphilis) and the evidence of amyloid 



THE STOMACH, LIVER, AND PANCREAS. 389 

in other organs (enlarged spleen, albuminuria, diarrhoea). The 
liver is smooth, not irregular as in hepatic syphilis. 

The leukasmic liver is recognized by blood examination; the 
pseudo-leuksemic liver by the normal blood and the histological 
examination of the glandular enlargements which always accom- 
pany it. 

Hydatid cyst is rarely to be diagnosed by physical signs. The 
history of a residence in Australia, Iceland, certain parts of Ger- 
many, or of the British Isles is important evidence, since the 
disease has never been known to originate in North America. Physi- 
cal examination may enable us to make out that the hepatic enlarge- 
ment is due to a cystic tumor, tense and elastic, with notable 
absence of constitutional disturbances (Rolleston). 

(c) Atrophy of the Liver. 

Diminution in the size of the liver can hardly ever be demon- 
strated satisfactorily during life, since we must rely upon percus- 
sion for our evidence, and percussion of the upper and of the lower 
border of the liver may be rendered difficult by distention of the 
lung (emphysema) or of the colon. Atrophy occurs in a small pro- 
portion of the cases of hepatic cirrhosis and in acute yellotv atrophy, 
but is rarely recognized in either condition. The rapidly fatal 
course of the latter disease with jaundice and a "typhoidal state " 
contrasts with the prolonged portal stasis characteristic of cirrhosis. 

(e£) Portal Obstruction. 

A characteristic group of signs manifest the presence of an ob- 
stacle to the flow of blood through the portal system. This group 
includes : 

1. Hsematemesis and dyspepsia. 

2. Ascites 1 (see page 372). 

3. Splenic enlargement. 1 

1 Ascites and splenic enlargement are not purely mechanical phenomena. 
Toxaemia and sometimes chronic peritonitis or cardiac failure contribute. 



390 PHYSICAL DIAGNOSIS. 

4. Collateral dilatation of veins about the navel and elsewhere. 

Hcematemesis is usually due to rupture of dilated oesophageal 
veins, occasionally to gastritis. 

Splenic enlargement is more marked in the rare cases associated 
with chronic jaundice {biliary cirrhosis) and without ascites. 

The cause of portal obstruction is: 1. Cirrhosis, in ninety-five 
per cent of the cases. The remaining five per cent is made up 
of : 2. Obliterations of the portal vein, usually by thrombosis or 
tumors. 

(e) Jaundice. 

The yellow staining of sclera, skin, and mucous membranes, 
with or without changes in the color of the urine and faeces, is 
known as jaundice. I have classed it as a general rather than a 
local sign of liver disease, because it may occur from toxaemia and 
independent of any lesion of the liver; for instance, in septicaemia, 
malaria, yellow fever, and pernicious anaema. It is true, never- 
theless, that all jaundice is due ultimately to obstruction in the 
path of the bile stream. In the toxaemic cases the obstruction is 
due to inflammation of some of the small ducts within the liver. In 
the cases due to stone or cancer the obstruction is in the larger bile 
ducts, usually the common duct. 

Causes of Jaundice. — The four types most often seen are: 

1. Jaundice of the new-born (occurs in from thirty to eighty per 
cent of all children). 

2. Catarrh of the bile ducts (" catarrhal jaundice "). 

3. Gall stones, especially in the common duct. 

4. Cancer (pancreas, glands, liver, or bile ducts). 
Less common are the cases due to : 

5. Cirrhosis of the liver. 

6. Syphilis of the liver. 

7. Infectious disease or toxaemia. 
Rare causes are : 

8. Acute yellow atrophy, with or without phosphorus poisoning. 

9. Weil's disease and other types of infectious jaundice. 

10. Congenital obliteration of the bile ducts. 



THE STOMACH, LIVER, AND PANCREAS. 391 

The results of jaundice upon the body are chiefly the following : 
(a) Slow pulse (often below 60). (b) Itching of the skin, (c) 
Mental depression, (d) Hemorrhagic tendency (which renders 
operation dangerous). 

In mild cases there is no bile in the urine; in severe cases it is 
almost always present. The stools are gray or clay-colored when 
the obstruction is in the larger bile ducts outside the liver, but in 
the toxsemic forms of jaundice abundance of bile passes into the 
intestine and the stools are of normal color. 

Diagnosis of the cause of jaundice depends on the following con- 
siderations : 

1. If it occurs during the first four days of life without any 
other symptom and passes off within a few weeks, we call it simple 
jaundice of the new-born. 

2. If the attack is preceded by gastro-intestinal disturbances, 
usually in a young person, if pain and hepatic enlargement are 
slight or absent, and if the jaundice passes off within six weeks, we 
term it " catarrhal jaundice" (though the pathology of this and of 
the preceding condition is unknown) . 

3. If there have been attacks of biliary colic (see below, page 
393), intermittent fever with intervals of good health, and no con- 
siderable or progressive enlargement of the liver or gall bladder, 
stone in the common duct is probably the diagnosis. 

4. Cancer of the pancreas, duodenal papilla, bile ducts, or of 
the glands at the hilus of the liver, produces enlargement of the 
gall bladder, pain, and a jaundice of the intensest type known. 
Loss of flesh and strength is rapid. Cancer of the liver itself gives 
a rapidly enlarging, nodular liver with steady pain, and, in fifty 
per cent of cases, jaundice. 

5. In ordinary portal cirrhosis the jaundice is less intense and 
permanent, portal stasis is usually evident, and there is generally 
a moderate enlargement of the liver. 

6. Enlargement of the liver with jaundice lasting for years in 
young people is called biliary cirrhosis. 

7. Hepatic syphilis produces jaundice in a small percentage of 
cases, and under these conditions is so apt to be mistaken for cancer 



392 PHYSICAL DIAGNOSIS. 

that I think all cases supposed to be cancer in or near the liver 
should be given a course of antisyphilitic treatment. Other lesions 
or symptoms of syphilis will naturally influence us. 

8. The jaundice secondary to septicaemia, yellow fever, malaria, 
and pernicious anaemia is usually slight and rarely shows in the 
urine or bleaches the stools. The evidence of the anaemia or of an 
infection makes evident the nature of the jaundice. 

9. Acute yellow atrophy cannot be determined without autopsy. 
Its chief symptoms are given in its name. 

10. Weil's disease is the term applied to some or all of the 
groups of infections of unknown origin which are accompanied by 
jaundice. From catarrhal jaundice it is to be distinguished during 
life only by convincing evidence of general infection. 

Congenital obliteration of the biliary ducts is suggested by the 
occurrence of congenital, intense, and permanent jaundice with 
hemorrhage and enlargement of the liver and spleen. 

(/) Loss of Flesh and Strength 

in cases presenting other signs of liver disease is commonest in 
uncompensated cirrhosis and in malignant disease, but may occur in 
gall-stone disease, syphilis, or abscess. I have known a physician 
greatly alarmed at his own rapid emaciation, though his symptoms 
(jaundice and colic) pointed to stone in the common duct and opera- 
tion proved this diagnosis correct. 

(</) The Infection Group of Symptoms. 

These symptoms — viz., fever, chills, sweats, leucocj^tosis, dis- 
turbances of digestion and sleep — are oftenest seen in : 1. Cholan- 
gitis. 2. Hepatic abscess. 1 3. "Ball- valve" or " floating " stone 
in the common duct. In the last disease jaundice is usually pres- 
ent ; in the others usually absent. In cancer of the liver fever and 
leucocytosis are often present, but the other signs of infection are 
rarely seen. 

1 With or without pylephlebitis. 



THE STOMACH, LIVER, AND PANCREAS. 393 



(Ji) The Cerebral Symptoms of Liver Disease. 

These vary from simple depression and apathy to delirium, con- 
vulsions, and coma. Severe symptoms are oftenest seen at the end 
of uncompensated cirrhotic cases ; eighty-two per cent of our fatal 
cases showed during the last days of life symptoms indistinguishable 
from those of uraemia. 

The Gall Bladder axd Bile Ducts. 

(a) Biliary colic, and (b) enlarged gall bladder, with or without 
tenderness and pain, are the data on which (with the evidence of 
local or general infection, cachexia, intestinal obstruction, and jaun- 
dice) our knowledge of gall-bladder disease is built up. 

Differential Diagnosis of Biliary Colic. 

Biliary colic, due to impaction of a gall stone in the cystic or 
common duct, is a sudden, agonizing pain in the gastric or hepatic 
region, radiating thence in all directions, with fever, chills, and 
vomiting. In most cases the attack lasts from three to twelve hours 
(Rollestone) unless relieved by morphine. The pains are said to be 
worse than those of labor, and are often accompanied by tenderness 
over the hepatic region. The liver or gall bladder is seldom pal- 
pable. Jaundice precedes or follows the attack in about one-half 
of the cases. 

Benal colic differs in that it usually starts over the kidney (in 
the back) and radiates down the ureter, while the urine is apt to be 
bloody but free from bile. 

Floating kidney produces pains which cannot in themselves be 
distinguished from biliary colic. The palpation of the floating 
Sidney may be all that makes us suspect that organ to be the cause 
of suffering. 

Peptic ulcer (gastric or duodenal) produces sharp, paroxysmal 
pain, but this usually follows a meal, can be relieved by alkalies, 
and produces no fever, chill, or sweat. Hyperchlorhydria may 



394 PHYSICAL DIAGNOSIS. 

produce similar pain at night (the commonest time for biliary colic), 
but is relieved by food or alkali. 

Lead colic is almost always associated with lead dots in the 
gams and stippling of the red corpuscles (see pages 24 and 470). 
The history of work as a painter or plumber and the absence of ten- 
derness assist the diagnosis. 

Enlarged Gall Bladder. 

An enlarged gall bladder cannot be felt unless it is stretched 
tight by its contents; a very tense gall bladder may be palpable 
without much enlargement. Probably most enlarged gall bladders 
are not tense, and so cannot be made out without operation. When 
palpable the organ presents as a smooth, rounded, pear-shaped tu- 
mor at the margin of the ribs in the nipple line. 

The causes of enlargement are : 

(a) Stone in the cystic dart, at the neck of the gall bladder. 

(lj) Cancer of the 'pancreas or other tumor obstructing the com- 
mon duct from without. 1 

(c) Cholecystitis. 

In the first of these jaundice is rarely present (ten to fifteen per 
cent — Eiedel 2 ), and colic with or without palpable tumor is our 
guide to diagnosis. 

In cancerous obstruction there is intense and permanent jaun- 
dice. 

In cholecystitis there is usually no jaundice, but all the signs of 
local and general infection — pain, tenderness, leucocytosis, and fever 
— are present. In acute cases the symptoms, however, may be 
indistinguishable from those of appendicitis, since the pain may 
be referred to the navel or even to the appendix region. Many 
mistakes of diagnosis between appendicitis and acute cholecystitis 
occur, and must occur until our present diagnostic resources are 
increased. 

1 Courvoisier has shown that if the common duct is obstructed by a gall 
stone the gall bladder is very rarely enlarged. 
2 Riedel: Berlin, klin, vY"och. : 1901, No, 3. 



THE STOMACH, LIVER, AND PANCREAS. 395 



Results of Cholecystitis. 

(a) Adhesions about the gall bladder may involve the duodenum 
or pylorus, and produce kinking and consequent dilatation of the 
stomach and chronic dyspepsia. 

(b) Intestinal obstruction (see below, page 401) is occasionally 
produced by the ulceration of a large gall stone from the gall blad- 
der into the intestine, usually the small intestine or duodenum. 

The Pancreas. 

Diseases of the pancreas can very rarely be diagnosed by our 
present methods. If greatly enlarged (tumor, cyst, hemorrhage) 
it may become palpable as a deep epigastric tumor, but we are 
rarely able to differentiate such tumors from those of the retro- 
peritoneal structures. 

Indirect and uncertain information is afforded by the presence 
in the urine of sugar or fat-splitting ferments 1 and in the stools by 
the appearance of an abnormal amount of muscle fibre or of fat not 
otherwise to be accounted for (i.e., in the absence of jaundice, diar- 
rhoea, tuberculous peritonitis, or large meals of fat). 

Cancer of the pancreas may sometimes be suspected on account 
of its pressure effects. Intense and permanent jaundice with en- 
larged (perhaps palpable) gall bladder and liver may be due to the 
pressure of cancer in the head of the pancreas upon the common 
bile duct. Ascites and swelled legs may be produced by compres- 
sion of the inferior vena cava. But the diagnosis can rarely be more 
than a suspicion, for cancer of the duodenal papilla or retroperi- 
toneal sarcoma may produce similar pressure effects. Should these 
pressure effects coincide with a glycosuria and the presence of a deep- 

1 The suspected urine is neutralized with potassium hydroxide and one 
portion of it boiled to destroy any ferment that may be present. To this and 
to the unboiled portion ethyl butyrate is added. In twenty-four hours an acid 
reaction may appear in the unboiled specimen if it contains a ferment, while 
the other specimen shows no considerable change in reaction. 



396 



PHYSICAL DIAGNOSIS. 



seated, almost immovable tumor, the suggestion of pancreatic disease 
becomes more plausible. 

Acute pancreatic disease, hemorrhagic or suppurative, is not rec- 
ognizable until it is seen at an operation undertaken for the relief 
of some grave, acute lesion of the upper abdomen. Perforated gas- 
tric ulcer and intestinal obstruction may give identical symptoms, 
viz., sudden, intense, epigastric'pain and tenderness, with vomiting 
and collapse. One or two days later a tender epigastric tumor may 
appear, but this presents no characteristic peculiarities. 

Pancreatic cyst presents a very slow-growing, possibly elastic, 
deep-seated epigastric tumor, which usually produces little in the 
way of pressure effects, and may be associated with glycosuria and 
fatty stools. 

Bronzed Diabetes. — The association of diabetes with bronzing of 
the skin and enlargement of the liver is strongly suggestive of 
chronic fibrous pancreatitis. 

In any doubtful case the possibility of pancreatic disease is 
increased: (a) If improvement follows the administration of pan- 
creatic preparation; (b) if glycosuria follows the administration of 
100 gin. of glucose (alimentary glycosuria). 



Incidence of Pancreatic Disease. 

The following table is from the Massachusetts General Hospital 
records (1870-1905) : 

Cases. 

Cancer of the pancreas 35 

Acute pancreatitis 13 

Chronic pancreatitis 10 

Cyst of the pancreas 3 

Total 61 



CHAPTER XX. 

THE INTESTINE, SPLEEN, KIDNEY. 
The Intestines. 

Incidence of Intestinal Disease (excluding diarrhoea and constipa- 
tion) at the Massachusetts General Hospital, 1870-1905. 

1. Appendicitis 3,314 

2. Acute obstruction 142 

3. Cancer (above the rectum) 155 

4. Dilated colon 6 

5. Tuberculosis 2 

6. Faecal impaction (above the rectum) 2 

Total 3,621 

Data for Diagnosis. 

The data on which are based all our conclusions regarding intes- 
tinal disease are obtained from the following sources : 

1. Pain (colicky or steady) and tenderness, tenesmus. 

2. Gaseous distention and the noises and sensations produced by 
gas. 

3. Diarrhoea or constipation. 

4. Muscular rigidity of the belly wall protecting an intestinal 
lesion. 

5. Tumor, palpable or visible, and believed to be connected 
with the intestines (together with the effect of catharsis on such 
tumor). 

6. Visible or payable peristalsis (see page 364). 

7. Digital or visual examination of the rectum (see page 441). 

8. Examination of the intestinal contents, faecal and other (see 
page 402). 

9. Inflation of the colon through the rectum (see page 370). 

10. Indicanuria — rarely of value. 



398 PHYSICAL DIAGNOSIS. 

11. Constitutional manifestations, such as fevers, vomiting, 
leucocytosis, emaciation. 

Some of these data need further comment. 

Intestinal Pain. — Many pains associated with intestinal disease 
(appendicitis, cancer) are due in fact to irritation of the peritoneum. 

Which of the numerous pains referred to the belly should be 
interpreted as intestinal in origin? Those especially which (a) 
shift rapidly from place to place ; (b) accompany the noises and 
sensations of the passage of gas and faeces through the intestine ; 
(c) accompany diarrhoea or constipation. 

Tenderness is usually a symptom of peritoneal rather than intes- 
tinal irritation. With true intestinal pain (colic) there is often 
relief by pressure — the precise opposite of tenderness. Yet so 
close is the association of intestine and peritoneum that in appen- 
dicitis, intestinal ulceration, tumors, and even in simple gaseous 
distention of the gut, there is often local or general tenderness. 
When extreme and associated with constitutional manifestations 
— fever, leucocytosis, collapse — it always suggests peritonitis. 
When there are no constitutional manifestions, a purely local pain 
or tenderness has little diagnostic value. 

Tenesmus. — The desire to pass another stool as soon as one has 
been evacuated, together with local burning and straining, means 
always rectal irritation (inflammation, ulcer). It is one of the most 
definite and reliable symptoms known. 

Gaseous distention of the intestine is proved by an increase of the 
normal tympanitic note over part or all of the belly, together with 
a prominence of the overlying belly wall. It is chiefly and most 
frequently the colon that produces distention. 

The significance of distention is vague and depends largely on 
the associated data. In acute g astro-intestinal " catarrh " the 
diarrhoea and absence of severe constitutional manifestations make 
us put little stress on the associated distention. In typhoid fever 
distention results from atony of the intestinal walls and is " to some 
extent a measure of the intensity of the local lesions " (Osier). In 
intestinal obstruction distention may be extreme if the stoppage is 
low down (in the colon), less marked if the lesion is high up. In 
starvation, children often get very large bellies, owing to muscular 



THE INTESTINE, SPLEEN, KIDNEY. 399 

atony of the gut and the resulting gaseous accumulation. But in 
no case is the distention of itself of much diagnostic value. The 
associated symptoms give it significance. 

Diarrhoea, the passage of more and looser stools than is normal 
for the individual* is, like distention, a result of many causes both 
within and outside the intestine. 

The most important are : 

C(a) Indigestion (acute and chronic). 
1 TntpqfiTinl di«efl«P J (*) Ulceration (some cases only), 
i. intestinal disease. < ^ Infectious diseases (cholera, dysentery, typhoid). 

[(d) Intestinal parasites. 

((a) Nervous causes (emotion, Basedow's disease, 
etc ) 
2. Outside influences, j (ft) Genera l infections (sepsis). 

[(c) Cachectic states (anaemias, nephritis, etc.). 

By a search for these causes, as well as by the use of the data 
obtained by examination of the stools, we arrive at an understand- 
ing of the diagnostic significance of diarrhoea. 

Aside from diarrhoea and constipation, which produce no physi- 
cal signs beyond those already described — distention, borborygmi, 
pain, tenderness, tenesmus, and constitutional manifestations — 
there are but three important lesions of the intestines ; 

I. Appendicitis. 

II. Intestinal obstruction. 

III. Cancer of the bowel. 

I. Appendicitis. 

1. The local signs are pain, tenderness, muscular spasm, and 
tumor. 

2. The general or constitutional signs are fever, chill, rapid 
pulse, vomiting, constipation, frequency or cessation of micturition, 
and leucocytosis. 

(a) The pain may be at first general, later localizing itself in the 
right iliac fossa, less often near the navel, the gall bladder, or in 
any other part of the belly. 

(ft) The tenderness is more important in diagnosis; indeed, with- 
out tenderness diagnosis is rarely possible. It is usually greatest 



400 PHYSICAL DIAGNOSIS. 

near a point half-way from the anterior iliac spine to the navel. 
Occasionally a tender point in the pelvis may be reached by rectal 
examination. 

(c) Muscular spasm over the appendix region is present in most 
cases, and, while it renders accurate palpation impossible, it is in 
itself so characteristic of the disease that we do not regret it. 

T^soas spasm occurs in a minority of cases. The patient leans 
his body forward and toward the right in walking, or, if recum- 
bent, draws up the right thigh to relax the spasm. 

(d) Tumor — about the size and shape of a lemon, ill-defined and 
tender— is felt in the right iliac fossa in many cases. It may be 
considerably larger and better defined if abscess has existed for sev- 
eral days, or it may be smaller and more sausage-shaped. 

(e) The constitutional signs may or may not be marked, accord- 
ing to the duration of the process, its virulence, and the degree of 
infection of the peritoneal cavity. The fever is usually moderate, 
under 102.2° F., with corresponding elevation of the pulse. Vom- 
iting comes at the outset if at all, and is usually over by the second 
day. A leucocyte count which rises or remains elevated (above 
16,000) accompanies the active and advancing stages of the disease. 
In cases that are very mild or tightly walled in by adhesions, and 
in cases with virulent general peritonitis, the leucocytes may be 
normal or subnormal. 

Diagnosis can hope only to establish the existence of a local 
inflammatory process in the abdomen ; acute cholecystitis and acute 
pus tube may present signs indistinguishable from those of appen- 
dicitis, though the site of tenderness often sets us right. Non- 
inflammatory processes, such as biliary and renal colic, floating 
kidney, and acute gastrointestinal upsets, can usually be excluded, 
since they do not show so much local tenderness, fever, and leuco- 
cytosis. 

In young women familiar with the symptoms of appendicitis, a 
vivid imagination may conjure up a set of sensations that are diffi- 
cult for the physician to distinguish from those of the actual dis- 
ease. Even tenderness may be simulated, but, by distracting the 
patient's attention while we palpate, we may be able to press hard 
over the appendix without eliciting complaint. The absence of leu- 



THE INTESTINE, SPLEEN, KIDNEY. 401 

cocytosis, the age and sex of the patient, also help us to exclude 
appendicitis. 

77. Intestinal Obstruction. 

(a) Acute Obstruction. — A person may have had no faecal discharge 
for a week or even considerably longer and yet present all the evi- 
dences of good health. It is only when vomiting, severe paroxysms 
of pain, and distention of the belly ensue that we suspect obstruc- 
tion. In the acute cases tumor is noted in only about fifteen per cent. 
In the chronic cases, usually due to stricture or cancer, a faecal 
tumor can often be felt and diarrhoea may alternate with constipation. 

By physical signs alone I do not believe that general peritonitis 
and acute intestinal obstruction can always be distinguished. Fever 
is not distinctive of general peritonitis, for it occurred in eighty-four 
out of one hundred and twenty-two cases of acute obstruction in the 
Massachusetts Hospital records, and in forty-three of these cases 
free fluid in the peritoneal cavity was demonstrated as well. Ster- 
coraceous vomiting may occur in general peritonitis ; it was absent 
in three-fourths of the Massachusetts Hospital cases of obstruction. 
Weak, rapid pulse, cold extremities, and a drawn, anxious face are 
common to both diseases. Tenderness is more general and more 
marked in general peritonitis than in simple obstruction, yet some 
tenderness was complained of in fifty-six out of the one hundred and 
twenty-two cases of obstruction just cited. 

On the whole, the differential diagnosis of these two diseases 
seems to depend far more on the history and the etiology than on 
physical signs. 

(b) Chronic Obstruction. — Here the diagnosis is simpler. There 
is usually a history of increasing constipation sometimes interrupted 
by occasional attacks of diarrhoea. 1 Tumor is palpable in fifty-eight 
per cent of cases. Visible peristalsis was recorded in seventeen per 
cent of the Massachusetts Hospital cases. Distention is gradual and 
late. Cachexia is frequently present. Cancer of the colon, usually 
at the sigmoid or caecum, is the commonest cause. Stricture, ex- 
cept cancerous stricture, is rare. 

1 The latter combination occurred in six per cent of the Massachusetts Hos- 
pital cases. 

26 



402 



PHYSICAL DIAGNOSIS. 



(c) Acute Obstruction by a Chronic Lesion. — Cancer of the sigmoid 
often exists for months almost latent, or produces only moderate 
constipation, so that the patient considers himself well. Such can- 
cers present an annular growth, hardly bigger than a signet-ring, 
practically an annular stricture. 

This stricture maybe suddenly "shut doicn" during an acute 
gastro-intestinal attack, and we are then confronted with all the 
signs of acute obstruction. Only the seat of the lesion, the age of 
the patient, and possibly the appearance of peristaltic waves can 
lead us aright in our diagnosis of the cause of obstruction. 

III. Cancer of the Bowel. 

The signs are usually those of chronic intestinal obstruction (see 
last section) with a well-defined tumor. Occasionally the tumor 
may not produce much obstruction, and we have simply pain and a 
tumor which we find by examination is not attached to the liver, 
spleen, kidney, or stomach, and usually about the size of a hen's 
egg. If faeces have accumulated behind such a tumor, we may feel 
larger masses. In my experience palpable tumors due to faecal im- 
paction alone, without organic stricture or cancer, are very rare, ex- 
cept in the rectum or lower sigmoid ; if found above this region they 
are almost invariably dependent on stricture or cancer of the bowel. 



Examination of Intestinal Contents. 



Anglo-Saxon," 



1. Weight. — With the average diet of the adult 
the weight of the daily stool is from 100 to 250 gm. (about 25 to 
70 gm. dry), but Chittenden has shown that with a low proteid diet 
of 2,000-2,750 calories value, the weight of the stool may be less 
than half this amount. 1 

2. Color. — («) White or light yellow — milk diet, bread and 
milk diet. 

(b) Black — blood, bismuth or iron (medicinal), blackberries, 
huckleberries, red wine. 

1 "Physiological Economy in Nutrition," 1904, p. 42. 



THE INTESTINE, SPLEEN, KIDNEY. 403 

(c) Green — normal infant's stool after standing; fermented 
infant's stool if green when passed; green vegetables, calomel. 

(d) Gray — absence of bile (jaundice), sometimes after cocoa or 
chocolate. 

(e) Bloody red — if in small amount and fresh, usually due to 
hemorrhoids; in large amounts it may also be due to hemorrhoids 
or to any of the causes of intestinal ulceration (typhoid, cancer, 
dysentery, etc.). 

3. Odor. — In adults of no great significance. In infants foul 
stools suggest albuminoid decomposition, and strongly sour stools 
suggest acid fermentation. 

4. Abnormal Ingredients. — (a) Undigested food in small quan- 
tities is present in normal stools, but when digestion is faulty larger 
quantities easily recognized by the naked eye may occur. Pieces 
of meat, flakes of casein (especially in typhoid patients overfed 
with milk), fragments of starchy food, and lumps of fat (steator- 
rhea) may be seen. 

The natural inference from the presence of these substances is 
that the gastro-intestinal tract is not at present dealing with them 
satisfactory. Fatty stools are present in jaundice, tuberculosis, 
or amyloid of the intestine, and even in simple catarrh. Though 
often associated with pancreatic disease, fatty stools are by no means 
characteristic of it. 

(b) Mucus. — Small shreds of mucus adherent to faeces are of 
no importance and cause much unnecessary worry among anxious 
mothers. Larger amounts, if intimately mixed with the stool, point 
to catarrh of the small intestine; if mucus thickly coats or makes 
up the bulk of the stool, the trouble is in the colon. The latter is 
by far the commonest condition. Anything from a very mild to a 
severe catarrhal condition is accompanied by mucus. 

(c) Fresh Blood. — Piles are by far the commonest cause of 
bloody stools, and the amount of blood may be trifling or may be 
large enough to produce in time a severe anaemia. 

Enteritis (the mild follicular or the severe ulcerative form) 
often produces bloody stools. The associated symptoms, diar- 
rhoea, mucus, and pain, together with the etiology (dietetic error, 



404 PHYSICAL DIAGNOSIS. 

typhoid fever, amoeba coli), must determine the nature of the en- 
teritis. 

In cancer of the rectum or sigmoid (rarely higher up in the 
bowel), small quantities of blood, fresh or altered, are almost 
alwaj'S passed sooner or later. The infrequent, offensive, and pain- 
ful stools and the results of digital examination usually reveal the 
source of the blood. 

In intussusception the association of bloody stools with the sud- 
den appearance of a painful abdominal tumor (usually in the caecal 
region), vomiting, and severe constitutional manifestations suggest 
the diagnosis. 

In hemorrhagic leases (purpura, scurvy, acute leukaemia) blood 
may come from the intestine as well as from the other mucous mem- 
branes. Other rare causes for blood in stools are a ruptured aneur- 
ism, thrombosed mesenteric artery, rectal syphilis, or fissure. 

{d) Altered blood (tarry stools, melaena) follows the pouring out 
of blood — a pint or more — in the upper gastro-intestinal tract, and 
occurs in hepatic cirrhosis, gastric or duodenal ulcer, after severe 
nose-bleed, and occasionally from other causes. 

(e) Pus is not of great diagnostic value. Large amounts mean 
the breaking of an abscess (appendix, pus tube) into the rectum. 
Small amounts occur in ulcers or even from catarrh. 

(/) Shreds of tissue point to ulceration. 

(g) Gall Stones. —In suspicious cases break up the faeces in a 
sieve with plenty of water. The peculiar, facetted shape of most 
gall stones should be familiar to the student from the study of mu- 
seum specimens. If the patient has been taking olive oil in large 
doses, pseudo-concretions made up of faecal matter and oil may de- 
ceive the inexperienced. 

Intestinal Parasites. 

Bacteria. — Only the tubercle bacillus can be recognized without 
culture methods, which do not fall within the scope of this book. 

For the identification of tubercle bacilli the following method is 
to be recommended: "Dilute the stool with ten volumes of water, 
mix thoroughly, and let it stand in a wide-mouthed bottle for 



CABOT-PHYSICAL DIAGNOSIS. 



PLATE I, 




/ \ 




Fig. 1.— Trichomonas lioininis. (Leuckart.) 




Fig. 2.— Balantidium coli. (Leuckart.) Magnified about 150 diameters. 




Fig. 3.— Lamblia intestinalis. (Leuckart.) 



THE INTESTINE, SPLEEN, KIDNEY. 405 

twenty-four hours. The narrow layer between the thin supernatant 
liquid and the solid sediment contains the bacilli. Kernove this 
with a pipette, spread it on a cover slip, evaporate slowly to dry- 
ness, and proceed as with sputum " (" Harvard Outlines of Medical 
Diagnosis," 1904, p. 29). 

Animal Parasites. 

The most important are : 

( 1. Amoeba coli. 

I. Serious ■] „ H r.nk worm i M Uncin aria americana. 

( Z - Hook - worm j (b) Anchylostoma duodenale. 

II. Mild 3. Tape- worms: the beef -worm (Taenia saginata) is very 

common ; the pork-worm (Taenia solium) is rare ; 
the miniature tape-worm (Taenia nana) and the 
fish-worm (Dibothriocephalus latus 1 ) are fairly 
common. Several other forms occur in foreign 
countries. 

4. Ascaris lumbricoides (round-worm). 

5. Oxyuris vermicularis (thread-worm ; pin-worm), 
j 6. Trichiuris trichiura (whip-worm). 

III. Usually J 7. Strongyloides intestinalis. 

harmless, j 8. Trichomonas intestinalis. 

I 9. Lamblia intestinalis. 

10. Balantidium coli. 

[ll. Bilharzia haematobium. 

Tape-worms, round-worms, pin-worms, and the strongyloides 
are to be recognized in their adult form (see Figs. 183, 184, 185, 
186, 187). They are usually noticed by the patients themselves 
and brought to the physician for examination. If the worm has the 
look of a common earth-worm, but a length of five to nine inches, 
it is safe to call it the " round-worm " (Ascaris lumbricoides); if the 
worm is about one-half an inch long and as thick as a pin, it is in 
all probability a "pin-worm" (Oxyuris vermicularis). 

The Amoeba coli is to be searched for in fresh stools passed into 
a warm vessel. A bit of mucus from such stools is put upon a 
warmed slide with a drop of water, covered with a cover glass, and 
examined at once with a high-power dry lens. It is recognized by 

! Fish tape-worms may produce a severe anaemia, but in probably the 
great majority of all cases they do not do so. 



406 



PHYSICAL DIAGNOSIS. 



the presence of distinct amoeboid movements. When dead it assumes 
a round shape, but one should not attempt a positive diagnosis un- 
less live amoeboid parasites are present. 

The other parasites are identified, as a rule, by the finding of 
their eggs in the stools. The technique of this operation is de- 
scribed below, as exemplified in the search for the egg of uncina- 
ria — at present the egg most important for Americans to recognize. 

Eggs of parasites catch the eye 
in the examination of stools, first of 
all, by the clean-cut, mathematical 
symmetry of their oval, when com- 





FIR. 183. 



-a, Head of Taenia saginata, much magnified ; Z>, uterine canal of same. About 
twenty branches on each side. 



pared with the irregular, shapeless masses which usually appear 
in slide and cover preparations from the faeces. 

Secondly, the size of parasitic eggs is greater than that of most 
of the objects seen in the faeces; and, thirdly, they are for the most 
part dark brown, stained vjith bile (the uncinaria is an exception). 

The differences between individual species will be described 
later. In Plates II. and III, the most important eggs are pictured 
and catalogued, 



CABOT-PHYSICAL DIAGNOSIS. 



PLATE II. 




Distoma buski. 



Ascaris lumbrieoides. 





Uncinaria amerieaua. 



Anchylostoma duodenale. 







Tricnuris trichiura. Dibothriocephalus Taenia solium, 

latus. 

EGGS OF INTESTINAL PARASITES. 
All are magnified 2.">0 diameters. 



Taenia saginata. 



THE INTESTINE, SPLEEN, KIDNEY 



407 



The Uncinaria americana or its European equivalent (Anchylos- 
toma duodenale) is recognized most easily by the identification of its 
eggs in the stools. These eggs are characteristic (see Plate II.), 
and " the only thing liable to be confounded with them is the ovum 
of Ascaris lumbricoides stripped of its heavy, bile-stained outer 
shell (see Plate II.) ; but this has a 
double contour and contains a shapeless 
mass of granular matter not differen- 
tiated" (as most uncinaria eggs are) 
"into clear segments." 1 The greater 





Fig. 184.— a, Head of Taenia solium (ncle crown of hooks) ; b, uterine canal in two segments. 
Only Are to seven branches on each side. 

size of the American hook-worm's egg compared to that of the 
European worm is shown in Plate II. " Free embryos are rarely 
if ever found in intestine. When free (worm-like) embryos are 
seen in the stools, they are generally those of the Strongyloides in- 
testinalis " (see Fig. 187). 



1 All the quotations iu this section are from the " Report of the Commis- 
sion for the Study and Treatment of Anaemia in Porto Rico," by Ashford, 
King, and Igaravidez (December 1st, 1904), a study of 5,490 cases. 



408 



PHYSICAL DIAGNOSIS. 



The ova of uncinaria catch the eye in a rapid examination, 
first*, because they are "not generally bile-stained, but clear, whereas 
those of the commonly associated intestinal parasites are of a yel- 
low to deep amber or brown color." 
They are distributed quite evenly 
throughout the entire faecal mass; 
hence, in searching for them, the 
following method is advisable : 

Technique of Microscopic Exami- 
nation. — " A bit of faeces the size of a 
match head is removed with a tooth- 
pick and placed on a glass slide. 
Upon this is placed a cover glass 
and pressed down so as to give a clear 





? & 



Fig. 185.— Taenia nana (Dwarf Tape-worm) . <x, Hooklet ; o, head, greatly enlarged ; c, whole 
worm, magnified about 10 times. 



centre to the specimen. Do not add water. Examine with a one- 
third to two-thirds objective, a No. 4 ocular, and a partially closed 
diaphragm. If too much light is admitted the delicate ovum will 
be passed over," 



THE INTESTINE, SPLEEN, KIDNEY. 



409 



The following interesting table (from the studies of Ashford, 
King, and Igaravidez in Porto Rico) shows, roughly, the relative 
frequency (in a tropical climate) of the common intestinal parasites 




Fig. 186.— Segments of the Eibothriocephalus latus (Fish Tape-worm). Note the rosette- 
shaped uterine marking. 



recognizable by their eggs. In the examination of the stools of 
5,490 cases of uncinariasis they found as well: 

Ascaris lumbricoides in 1,408 (many others seen but not noted). 

Trichuris trichiura in 326 (many others seen but not noted). 

Strongyloidesintestinalisin. . 36 (the embryo worms, not eggs). 

Bilharzia haematobium in.. . . 21 (frequently no careful search 

was made for this egg). 

Balantidium coli in 14 

Oxyuris vermicularis in 3 

Amoeba coli in 3 

Taenia saginata in 2 

Taenia solium in 2 

Ascaris lumbricoides has usually a thick, wavy (" mammillated ") 
shell; but this is not always seen, and in its absence the egg is dis- 
tinguishable from Uncinaria americana chiefly by the absence of 
the segmentation usually seen in the egg of the latter (see Plate 

ii., b). 

Trichuris trichiura (also called Tricocephalus dispar) has a thick 
shell, very dark-stained, and apparently pointed and perforated at 



410 



PHYSICAL DIAGNOSIS. 



each end, instead of curving evenly over as the uncinaria egg does 

(see Plate II., c). 

Bilharzia eggs are not at all uncommon in the faeces, though 
more often described in the urine, in con- 
nection with hematuria. The terminal 
spine at one end is their most character- 
istic feature (see Plate II., d). 

The other eggs are briefly described in 
the explanatory text accompanying Plate 
II. 

The Spleen. 

Diseases of the spleen (abscess, malig- 
nant disease) are almost never recognized 
during life. It is for evidence of splenic 
enlargement as a factor in the diagnosis of 
diseases originating elsewhere that we in- 
vestigate the splenic region as part of the 
routine of abdominal examinations. 

Splenic enlargement is detected chiefly by 
palpation. Percussion plays a minor role 
in the determination of the organ's size, 
and should never be relied on in the absence 
of palpable evidence. Palpation is easy, 
provided the organ is enlarged sufficiently 
to project beyond the ribs without forced 
respiration, but much practice is needed 
when the enlargement is slight, as in, for 
example, most cases of typhoid fever. 



Palpation of the Spleen. 

The co-operative action of both hands 
fig. 187.— strongyioides ster- ^ s as essential as in vaginal examination, and 

coralis. Magnified about 250 ° 7 

diameters. (After Thayer.) each hand must do the right thing at the right 




CABOT-PHYSICAL DIAGNOSIS. 



PLATE III. 



Heterophyes 
heterophyes. 



Distoma 
sinense. 



Bilharzia 
haematobium. 




Faseiola hepatica. 



Taenia soliuu 




Diplogonoporus 
grandis. 




Distoma buski. 




Bilharzia Dibotbrio- 

haematobium. cephalus latus. 



Distoma 
felineum. 



Dietocoelium 
lanceolatum. 




Bilharzia 
haematobium. 




Ascaris 
lumbrieoides. 



Oxyuris 
vermicularis. 




Paragonimus 

westermani. 




Taenia nana. Ascaris 

lumbrieoides. 



Anchylostoma 
duodenale. 




Uncinaria 

americana. 






Strongylus 

subtilis. 




Strongyloides 
stercoralis. 



DRAWINGS OF EGGS OF INTESTINAL PARASITES. 
All are magnified 250. (After Looss). 




W 

Trichuris 
trichiura. 



THE INTESTINE, SPLEEN, KIDNEY. 



411 



moment. The patient should be on his back, his head comfortably 
supported and his knees drawn up. The left hand, placed over the 
normal situation of the spleen, (a) draws the whole splenic region 
downward and inward toward the expectant finger-tips of the right 
hand; (b) at the same time the left hand should slide the skin and 




Fig. 188. -Position of tue'Hands in Palpation of the Spleen. 



subcutaneous tissues over the ribs and toward the right hand (see 
Fig. 188), so as to leave a loose fold of skin along the margin of the 
ribs and give the palpating fingers a slack rather than a taut cover- 
ing to feel through. 

The right hand lies on the abdominal wall just below the margin 
of the ribs, and the lingers should point straight up the path down 
which the spleen is to move, i.e., obliquely toward the left hypo- 
chondrium. With the hands in this position ask the patient to 
draw a full breath. Keep the hands still and do not expect to feel 
anything until near the end of inspiration. Then draw the hands 
slightly toward each other and dip in a little with the right finger- 
tips, so that if the spleen issues from beneath the ribs its edge will 
meet the finger-tips for an instant and spring over them as they 
rise from diving into the soft tissues (see Fig. 188). 

Some physicians have the patient lie on the right side, and, 



412 PHYSICAL DIAGNOSIS. 

standing behind him, hook their fingers over the ribs in the left 
hypochondrium. In this way we may be able to feel the spleen at 
the end of a long inspiration, but I have never found this position 
as useful as that described above. 

A hard, fibrous spleen (malaria) is much easier to feel than a 
soft one (typhoid). 

Percussion of the Spleen. 

Only when the edge of the spleen has been felt is it worth while 
to try to define its upper border by percussion. Normally there is 
dulness in the midaxillary line from the ninth to the eleventh ribs, 
corresponding to that part of the spleen that is most superficial. 
Its lower and posterior borders cannot be defined; its anterior edge 
is approximately in the midaxillary line (see Fig. 38). If this 
small area of dulness is enlarged upward and forward, and if the 
edge has been felt below the ribs, it is probable that the increased 
area of dulness corresponds to an enlargement of the organ. 

Causes of Splenic Enlargement. 

Slight enlargement of the spleen can often be detected in : 

1. Rickets and other debilitating conditions of childhood with or 
without anaemia. 

2. Malaria. 

3. Typhoid fever. 

In other acute infections slight enlargement can usually be 
made out post mortem, but not during life. 
Marked enlargement (chronic) occurs in : 

1. Chronic malaria — 8 per cent of my series. 

2. Hepatic cirrhosis — 30 per cent of my series. 

3. " Splenic anaemia " — 4 per cent of my series. 

4. Leukaemia (of any type) — 35 per cent of my series. 

5. Hodgkin's disease — 6 per cent of my series. 

6. Amyloid — 1 per cent of my series. 

7. Without known cause (" primary " or " idiopathic " spleno- 
megaly) — 12 per cent of my cases. 

Rare causes are abscess, tuberculosis, malignant disease, perni- 



THE INTESTINE, SPLEEN, KIDNEY. 413 

cious anaemia, polycythemia, hydatid, and Leishman-Donovan dis- 
ease — all of these together make 4 per cent of my series. 

Differences Between a Large Spleen and Tumors (of the kidney or 
other organs). — A large spleen is easily recognized after a little 
practice. As it enlarges it keeps its shape and advances obliquely 
across the belly toward the navel or (in marked cases) beyond it. 

It is always hard and smooth of surface, although the edge near- 
est the epigastrium shows one or more notches which are very char- 
acteristic. The edge is sharp, never rounded, and the whole organ 
is very superficial, being covered only by the belly walls, so that if 
we innate the colon (by forcing air into the rectum with a Davidson 
syringe), it passes behind the spdeen and does not obliterate its dul- 
ness. 

Tumors of the kidney fill out the flank, and an impulse can be 
transmitted to the lumbar region by bimanual palpation. They 
have no sharp edge or notches, are often irregular of surface, and 
not so superficial. The inflated colon passes in front of a tumor of 
the kidney and obliterates the d illness due to it. 

All these differences hold for any other tumors likely to be con- 
fused with an enlarged spleen. 

Differential Diagnosis of the Various Causes of Splenic 
Enlargement. 

In children splenic enlargement without fever or leuksemic blood 
changes is to be classed as a manifestation of general debility. It 
has no special connection with any type of anaemia, though anaemia 
is often seen with it. 

In typhoid the fever and the Widal reaction are generally suffi- 
cient to make clear the cause of the splenic enlargement; in active 
malaria the blood parasites are always demonstrable, and in chronic 
cases the history and the locality are significant. 

Hepatic cirrhosis (said Banti's disease) should show evidences of 
portal stasis (ascites, jaundice, haematemesis). 

Splenic ancemia means simply an anaemia of unknown origin 
associated with an enlarged spleen. 

Leukcemic enlargement of the spleen is easily recognized by the 
characteristic blood picture. 



414 PHYSICAL DIAGNOSIS. 

Hodgkin's disease shows glandular enlargements in the neck, 
axillae, and groins, with normal blood. Histological examination 
of an excised gland is necessary for diagnosis. 

Amyloid can be suspected (never positively diagnosed) as the 
cause of an enlarged spleen, if there is a history of syphilis or 
chronic suppuration (hip abscess, phthisis, etc.). 



Diseases of the Kidney. 

Incidence of Renal Disease (Massachusetts General Hospital, 1870- 

1905). 

Acute nephritis 200 

Chronic glomerulo-nephritis . 417 

Chronic interstitial nephritis. , 250 } 

Amyloid nephritis 9 

Floating kidney 227 

Stone in the kidney 145 

Malignant disease 42 

Tuberculous kidney 41 

Pyonephrosis and abscess 54 

Perinephritic abscess 35 

Hydronephrosis 19 

Cystic kidneys 10 

Total 1,449 

We get evidence of diseases of the kidney in three ways : 

1. By external examination of the region of the kidney. 

2. By examination of the urine. 

3. By study of the etiology and of the more indirect constitu- 
tional effects of the renal trouble — fever, leucocytosis, emaciation, 
anaemia, uraemia, dropsy, cardiac hypertrophy. 

Local examination acquaints us with the presence of tenderness 
and tumor. 

(«) Tenderness is present usually in abscess of the kidney (tu- 
berculous or non-tuberculous) and in perinephritic abscess, less 
often in connection with nephrolithiasis, occasionally in hydrone- 

1 Seven hundred and seventy -five other cases of " nephritis " not further 
specified. 



THE INTESTINE, SPLEEN, KIDNEY. 4l5 

phrosis and malignant disease. A floating kidney has usually an 
exquisite and peculiar sensitiveness to pressure, which differs from 
ordinary tenderness. 

(&) Tumor in the kidney region may occur in abscess in or 
around the kidney (including tuberculosis of the kidney and pyo- 
nephrosis), malignant disease, hydronephrosis, and cystic kidney. 
The latter members of this list afford examples of the largest tu- 
mors associated with the kidney. 

Characteristics Common to Most Tumors of the Kidney. 

Eenal tumors are best felt bimanually, one hand in the hypo- 
chondrium and the other in the region of the kidney behind, with 
the patient in the recumbent position. In this way the tumor may 
often be grasped and an impulse transmitted from hand to hand. 
It is usually round and smooth, often very hard, less often fluctu- 
ating. It descends slightly with inspiration. If the colon is in- 
flated by forcing air into the rectum with a Davidson syringe, res- 
onance appears in front of the tumor; this serves to distinguish it 
from tumors of the spleen which are pushed forward by the inflated 
colon as it passes behind them. Tumors of the kidney never pre- 
sent a thin and sharp edge, like that of the spleen. Occasionally 
they are irregular and nodulated — a condition almost never found 
in the spleen. 

(a) Malignant disease of the kidney, which is usually sarcoma, is 
much commoner in children than in adults, and makes up the great 
bulk of the large abdominal tumors occurring in childhood. The 
characteristics of the tumor are those already described, except that 
in advanced stages the tumor pushes forward from its position in 
the loin until it may reach the umbilicus or even fill the abdomen. 
Nodular irregularities can usually be felt. There may be emacia- 
tion and anaemia, sometimes leucocytosis, and often haematuria. 
Fragments of the tumor are very rarely found in the urine. 

(ft) Hydronephrosis and cystic kidney may be indistinguishable 
from each other unless the hydronephrosis is intermittent and dis- 
appears with a great gush of urine, or unless the cystic kidney is bi- 
lateral — as, indeed, is usually the case. In both diseases a smooth, 



416 



PHYSICAL DIAGNOSIS. 



round tumor forms in the loin and hypochondrium, usually without 
much constitutional disturbance and very frequently with a urine 
like that of chronic interstitial nephritis (see below) (see Fig. 189). 
Pain and tenderness are slight. The tumor may be astonishingly 
hard and often gives no sign of fluctuation. With cystic kidney it 
may be coarsely lobulated. Like other tumors of the kidney it de- 
scends slightly on inspiration. Cystic kidneys are often. congenital, 
but usually produce no symptoms until they have attained a consid- 
erable size, and hence are often overlooked or discovered accident- 
ally. In hydronephrosis the diagnosis may be assisted by etiological 

hints, such as an abnormal degree 
of mobility of the kidney on the 
affected side, a history of renal 
colic with or without hematuria, 
or a prostatic obstruction. 

(r:) Perinephritic abscess usually 
works its way to the surface in the 
back, between the crest of the ilium 
and the twelfth rib. This was the 
situation of the external tumor in 
25 out of 35 cases recorded at the 
Massachusetts General Hospital. 
A tender swelling appears at the 
point just described, sometimes 
with redness and heat, and almost 
always with fever, chills, leuco- 
cytosis, and some emaciation. The 
urine may show nothing abnormal 
or may show the evidence of cys- 
titis, of concomitant nephritis, or, 
rarely, of an abscess within the kidney itself. Perinephritic ab- 
scess often remains latent for weeks or months, and the amount of 
pus accumulated may be a quart or more. 

(d) Abscess of the kidney, including tuberculous, suppurating kid- 
neys and pyonephrosis, usually produces a smooth, round tumor in 
the hypochondrium and loin. It has the characteristics common to 
most renal tumors (see last page), but is usually distinguishable by : 




Fig. 189.— Left Hydronephrosis. 



THE INTESTINE, SPLEEN, KIDNEY. 417 

1. The etiology (cystitis, stone in the kidney, tuberculosis else- 
where). 

2. The presence of renal pyuria (see below, page 421). 

3. The presence of fever, leucocytosis, and the usual constitu- 
tional signs of an infectious process. 

(e) Floating Kidney ; Displaced and Movable Kidney. — The tip 
of the right kidney is palpable in most thin persons with loose belly 
walls. If the whole organ is palpable but not movable, we speak 
of it as displaced. If the range of mobility is relatively great we 
call it floating • if relatively slight we call it movable. With biman- 
ual palpation (as described above) we exert pressure just at the end 
of a deep inspiration and maintain it. During expiration something 
smooth and round may then be felt to slip upward between our 
hands toward the ribs. If the kidney "hides" behind the ribs, 
have the patient sit up, cough, and breathe deeply; then repeat the 
bimanual palpation as he lies on his back. Very movable or float- 
ing kidneys may be found far from their normal home, and are then 
recognized by: 1. Their size, shape, and " greasy " feel. 2. The 
sickening pain produced by pressure. 3. The possibility of replac- 
ing them. 

Renal Colic and Other Renal Pain* 

Typical renal colic is paroxysmal, like all colics; that is, an at- 
tack begins suddenly, ends suddenly, and lasts but a few hours or 
less. The pain usually begins in the back, over the kidney, and 
follows the course of the ureter to the groin. During an attack the 
testicle on the affected side may be tender and drawn up tightly by 
contraction of the cremaster. 

When associated with hematuria or pyuria, with or without sud- 
den stoppage of water during an attack and without any general or 
constitutional symptoms between attacks, renal colic is strongly sug- 
gestive of stone in the pelvis of the kidney; but similar attacks may 
occur with other surgical diseases of the kidney, with tuberculosis, 
with kinking of the ureter, and occasionally without any cause dis- 
coverable at operation. 

From biliary colic it may be distinguished by the {a) different 
27 






418 PHYSICAL DIAGNOSIS. 

situation of the pain, (b) by the presence of blood or pus in the 
urine, and (c) the absence of jaundice in this or a former attack. 

From DietVs crisis (severe colicky pain occurring in connection 
with floating kidney), renal colic is distinguished by the absence of 
abnormal mobility of the kidney and by the situation and course of 
the pain. 

In intestinal colic the pain shifts its position frequently and is 
associated with noises produced by wind in the bowels, or with diar- 
rhoea or constipation. 

Renal pain, not colic, occurs in almost any disease of the kidney 
except nephritis, and is characterized by its situation over the ana- 
tomical seat of the kidney and by the lack of any connection with 
muscular movements (lumbago) or with spinal movements (hypertro- 
phic arthritis). 

I have now described what seems to me most important in the 
local external examination for kidney disease, and have mentioned, 
along with the different lesions producing tumor, the general con- 
stitutional manifestations which are of assistance in diagnosis. 
Aside from the local and the constitutional evidence of renal disease, 
we have only the evidence afforded by the urine, to which I now 
pass on. 

Examination of the Urine. 

The urine as passed per urethram is a resultant and reflects the 
influence of many different organs and surfaces. Thus disturb- 
ances of metabolism, such as diabetes, intoxications (lead, arsenic), 
diseases of the heart, liver, and intestine, febrile conditions, infec- 
tive or malignant disease of any part of the urinary tract (kidney, 
ureter, bladder, or urethra), as well as the different types of ne- 
phritis, all affect the urine, though hardly any of them produce 
pathognomonic changes in it. In this section I shall consider the 
urine as a piece of evidence in the diagnosis of kidney disease, and 
only in contrast with this will its characteristics in extrarenal 
troubles be mentioned briefly. 

The most essential features of the urine in the diagnosis of kid- 
ney disease are : 

1. The amount passed in twenty-four hours, measuring sepa- 



THE INTESTINE, SPLEEN, KIDNEY. 419 

rately the portions passed at night (8 p.m. to 8 a.m.) and in the 
daytime (8 a.m. to 8 p.m.). 

2. The specific gravity. 

3. The looks (optical properties). 

4. The reaction to litmus. 

Much less important than these are the microscopic and chemi- 
cal examinations (albumin, casts, etc.). 

The Amount and Weight of the Urine. 

The twenty-four-hour amount concerns us chiefly in diabetes and 
the different types of nephritis. 

Polyuria occurs in health after the ingestion of large quantities 
of water, and sometimes in conditions of nervous strain. In dis- 
ease it characterizes both forms of diabetes, cirrhotic kidney (pri- 
mary, secondary, or arteriosclerotic), and is seen during the con- 
valescence from acute nephritis and from various infectious diseases. 
In diabetes of either form several quarts or even gallons may be 
passed. In cirrhotic kidney the increase of urine occurs very largely 
at night, so that the amount may be double that passed in the day- 
time, just reversing the conditions of health. 

Oliguria or scanty urine occurs in health when the amount of 
water ingested is small or when water is passed out of the body 
abundantly through the skin or by the bowels (diarrhoea). In dis- 
ease oliguria or absolute suppression of urine (cinuria) occurs at the 
beginning of acute nephritis and as a result of occlusion of one or 
both ureters by stone or malignant disease. x Remarkable examples 
of anuria also occur in hysteria. Infectious fevers and cachectic 
states often diminish the secretion of the urine by one-half or more. 

The specific gravity is usually low with polyuria and high with 
oliguria, but in diabetes mellitus the presence of the sugar gives us 
polyuria with high specific gravity. 

Total Urinary Solids. — By multiplying the last two figures of 
the specific gravity by the number of ounces of urine passed in 

1 It is a remarkable but well-attested fact that when one ureter is suddenly 
blocked both kidneys may stop secreting for the time. Yet when one kid- 
ney is gradually destroyed as in tuberculosis, the other hypertrophies so as 
to assume the function of both. 



420 PHYSICAL DIAGNOSIS. 

twenty-four hours and the product by 1:1, we get a figure represent* 
ing the total urinary solids in grains, with accuracy sufficient for 
clinical diagnosis. Thus if 30 ounces of urine are passed in 24 
hours and the gravity is 1.020, then 20 X 30 X 1.1 = 660 grains. 
The significance of this figure will be discussed later (see page 428). 

Optical Properties. 

Color. — Dilute urines (polyuria) are generally pale, and concen- 
trated urines (oliguria) high in color. A dark or brownish tint in 
the urine is generally produced by bile, by blood pigment, or as a 
result of certain drugs — carbolic acid, coal-tar preparations, and 
salol. If the color is due to bile, a bright canary yellow appears in 
the foam after shaking up a little of the urine in a test tube. No 
other tests for bile are necessary. Urines darkened by blood pig- 
ment show abundant blood corpuscles in the sediment; 1 when the 
color is due to drugs we can usually learn this fact from the his- 
tory. 

Turbidity in alkaline urine is usually due to the presence of bac- 
teria. In acid urine it is produced in a great majority of cases by 
amorphous urates, and disappears on heating the urine, while the 
turbidity due to bacteria is unaffected b} T heat. Xormal urine may 
be turbid and alkaline, owing to the presence of insoluble carbo- 
nates and phosphates, but clears on the addition of acetic acid. 
Hence turbidity, not removed by heat or acetic acid, is almost 
always due to bacteria, i.e., to cystitis, pyelonephritis, or both. 

Shreds seen floating in the urine are presumptive evidence of 
urethritis, and practically always of gonorrhoea. 

The gross sediment as seen by the naked eye amounts in health 
to nothing more than a slight cloud, which settles in the lower part 
of the vessel containing the urine. This cloud is somewhat denser 
in women than in men, owing to the presence of vaginal detritus. 
When the gross sediment amounts to anything more than this, it is 
almost invariably made up of (a) pus, (b) blood, or (c) urates. 
The latter are dissolved on heating. Pus has usually its ordinary 
yellow color and general appearance. Blood may be somewhat 

1 Except in some cases of hemoglobinuria. 



THE INTESTINE, SPLEEN, KIDNEY. 421 

lighter or somewhat darker than under ordinary conditions, but is 
usually recognized without difficulty. 

Significance of these Sediments. — A urate sediment means 
nothing more than a concentrated urine standing in a cold room. 
In the winter-time patients often bring us, in great alarm, a bottle 
of milky or fawn-colored and turbid urine, which is not in any way 
abnormal. The urates have been precipitated over night by the low 
temperature of the bedroom. 

Pyuria, or gross pus in the urine, is oftenest seen in cystitis 
and next often in pyelonephritis and renal suppurations. The pus 
occurring in gonorrhceal urethritis is usually much less in quantity 
than that coming from the bladder or kidney, and can be distin- 
guished by the local signs of gonorrhoea. Leucorrhceal pus can be 
excluded by withdrawing the urine by catheter. The rupture into 
the urinary passages of an abscess from the prostate or any part of 
the pelvis may produce a profuse but transient pyuria. 

After excluding gonorrhoea, leucorrhcea, and abscess, which can 
usually be done with the help of a good history and a catheter, we 
have left cystitis and renal suppurations, which it is very important 
and sometimes difficult to differentiate. In both we have the fre- 
quent and painful passage of small quantities of a urine which is in 
no way remarkable except in containing large amounts of pus and 
bacteria. 

In many cases the differentiation may be accomplished as fol- 
lows : Have the patient save for twenty-four hours the urine voided 
at each passage in a separate bottle (all of the bottles being of uni- 
form size), and mark each bottle with the hour at which it was 
rilled. Then arrange the specimens in a row, beginning with that 
passed earliest and ending with that passed last. Now if the case 
is one of cystitis without involvement of the kidney, the amount of 
pus that settles is practically the same in each bottle (allowing for 
differences in the amount of urine in the different bottles). But if 
the pus comes from the kidney, it is almost always discharged in- 
termittently, and hence some of the bottles will be almost free from 
sediment, while in a group of the others the amount of pus increases 
as we pass along the line, readies a maximum in one or two bottles, 
and. decreases again in those representing the later acts of micturition. 



422 PHYSICAL DIAGNOSIS. 

Pus from the bladder is generally alkaline, although in tubercu- 
losis it may be acid; pus from the kidney is generally acid. When 
both organs are involved, as is frequently the case, we have a mixt- 
ure of the characteristics of both types of pyuria, and cystoscopic 
examination with or without catheterization of the ureters is usually 
necessary. 

In renal pyuria we often have local signs in the renal region 
(tumor and tenderness), a history of renal colic, and decided con- 
stitutional symptoms. 

In vesical pyuria we have vesical pain, often tenesmus, no renal 
pain or tumor, and usually slighter constitutional symptoms. The 
amount of squamous epithelium (see below) is sometimes larger in 
cystitis than in renal suppurations, but no reliable inferences can be 
drawn from the size or shape of the cells. 

To determine whether pus from the bladder or the kidney is tu- 
berculous or non-tuberculous in origin, we usually inject the sedi- 
ment into a guinea-pig, which develops tuberculosis or not accord- 
ing to the nature of the pus injected. This method is much more 
reliable than the bacteriological examination of the sediment, for 
besides the tubercle bacillus other bacilli which retain fuchsin and 
resist decolorization by strong mineral acid and by alcohol occasion- 
ally occur in the urine. 

Hematuria. — In searching for the source of the blood we must 
be sure to exclude the female genital organs. Menstrual blood and 
uterine bleeding from various other causes often contaminate the 
urine, and must be excluded by using a catheter. 

The causes of true hematuria, arranged approximately in the 
order of frequency, are : 

1. Early cystitis. 

2. Stone in the kidney (less often vesical stone). 

3. Acute nephritis and acute exacerbation of chronic nephritis. 

4. Tumors of the kidney or bladder. 

5. Tuberculosis of the kidney or bladder. 

Less common causes are : floating kidney, acute infectious fevers 
(malaria, smallpox), animal parasites in the urinary passages, poi- 
sons (turpentine, carbolic acid, cantharides), hemorrhagic diseases 



THE INTESTINE, SPLEEN, KIDNEY. 423 

(purpura, scurvy, leukaemia), trauma and renal infarction, angio- 
neurotic and other mystical conditions. 

In cystitis there are bladder symptoms — pain, tenesmus, fre- 
quent and painful micturition. The blood is mixed with pus and 
epithelium, and is especially abundant in the urine passed near the 
end of the act of micturition. If the bladder is irrigated it is hard 
to get the wash- water clear. 

In renal stone there are no bladder symptoms to speak of, the 
blood is pure and thoroughly mixed with the urine, and if the blad- 
der is washed out the final wash water is clear. There is often 
renal colic (see below) and sometimes the passage of stones or 
gravel by urethra. 

In acute nephritis the blood is rarely fresh, generally dark choc- 
olate in color. The twenty-four-hour amount of urine is small, 
and albumin and casts (see below) are abundant. General oedema 
is common. Local symptoms in the kidney or bladder are absent. 

In renal tumor or tuberculosis we have often pyuria and the local 
and constitutional evidences above described (page 416), with an 
absence of bladder symptoms (provided the bladder is not also 
diseased) . 

Tumors of the bladder need cystoscopy for diagnosis. 

In the diagnosis of the rarer forms of haematuria we rely chiefly 
on the history (trauma, poisons ingested) and on the evidences 
afforded by general physical examination. 

Chemical Examination of the Urine. 
I. Reaction of Normal Urine. 

The reaction of normal urine is acid to litmus, except tempora- 
rily after large meals. Its acidity becomes excessive in fevers or 
occasionally without any known cause. 

Alkaline urine has generally an ammoniacal odor and suggests 
cystitis. As a result of decomposition and bacterial fermentation all 
urine becomes alkaline (ammoniacal) on standing exposed to air. 1 

Simultaneously a dark-brown color rarely appears: alkaptonuria, a fact 



424 PHYSICAL DIAGNOSIS. 

Occasionally we find urine alkaline from fixed alkali and without 
known cause. 

The value of the litmus test is chiefly as prima- facie evidence of 
stasis in the bladder and cystitis. Occasionally tuberculous cystitis 
and the first stages of any variety of cystitis are associated with 
acid urine, but in almost all cases lasting over a week amnioniacal 
fermentation and alkalinity appear. 

II. Albuminuria and the Tests fur It. 

Serum albumin is the only variety of clinical importance, and 
for this but two tests are necessary: (1) Nitric-acid test: (2) test 
by boiling. 

The n (trie-acid test is best performed in a small wineglass. 

After filling this half full of urine, insert a small glass funnel to 
the bottom of the urine and gently pour in concentrated nitric acid. 
If albumin is present, a white ring forms at the junction of the acid 
with the urine, either immediately or in the course of ten minutes. 
If carefully performed this test is delicate enough for all clinical 
purposes, but since some of the albumoses give a similar precipitate, 
the boiling test should be used as a control whenever a positive re- 
action is obtained with nitric acid. Xone of the other rings, ob- 
servable above or below but not at the junction of the acid with the 
urine, is of any clinical importance. 

The Boiling Test. — To half a test tube full of urine add three or 
four drops of dilute acetic acid, and boil the upper three-quarter 
inch of the urine. If albumin is present a white cloud appears. If 
albumose is present a white cloud appears on heating, disappears on 
boiling, and reappears on cooling. In performing this test the ad- 
dition of acetic acid as above described is absolutely necessary to 
prevent error. 

For the detection of albumin no other tests are needed. For its 
approximate quantitative estimation, Esbach's method is the best. 

Tsharh's Method. — A special tube (see Fig. 190; is employed. 

at present of no clinical significance except that such urines reduce Fehling*s 
solution and may he mistakenly supposed to contain sugar. 



THE INTESTINE, SPLEEN, KIDNEY. 



425 



Urine is poured in up to the mark " IT," and then Esbach's reagent ' 

up to the mark "R." The tube is then corked, inverted about half 

a dozen times, and set aside for twenty-four hours. A precipitate 

falls and the amount per mille is then read off on 

the scale etched upon the tube. If the urine is not 

acid it must be made so with dilute acetic acid, and 

unless its specific gravity is already very low it should 

be diluted once or twice with water so as to bring 

the gravity below 1.008. After such a dilution we 

must, of course, multiply the result obtained by a 

figure corresponding to the dilution. The method 

is not accurate, but is probably accurate enough for 

practical purposes. 

III. Significance of Albuminuria. 

It is important to realize that albuminuria very 
often occurs without nephritis and that nephritis oc- 
casionally occurs without albuminuria. Among the 
more important types not due to kidney disease are 
the following : (1) Febrile albuminuria; (2) albumi- 
nuria from renal stasis; (3) albuminuria due to pus, 
blood, bile, or sugar in the urine; (4) toxic albuminuria. 

Besides these, there are a good many cases of 
albuminuria occurring in diseases of the blood, after 
violent exertion, after epileptic attacks, and without 
any known cause. Many of the latter group occur 
only in the daytime when the patient is in an upright 
position, and are absent as long as the patient lies 
down (orthostatic albuminuria)', others occur inter- 
mittently and sometimes at regular intervals (cyclic 
albuminuria) . 

Exclude fever, circulatory disturbance, irritants, poisons — such 
as cantharides, turpentine, carbolic acid, and arsenic -and deposits 

Esbach's reagent: Picric acid, 10 gm. ; citric acid, 20 gm. ; distilled water, 
1,000 c.c. 



Fig. 190. — Es- 
bach's Albu- 
menometer. 



426 PHYSICAL DIAGNOSIS. 

of blood or pus in the urine, before deciding that a case of albumi- 
nuria is due to nephritis. To exclude the cyclic and orthostatic 
varieties is more difficult, and some authorities believe that these 
represent true nephritis in a more or less latent stage. In general, 
however, it is a good rule not to attribute albuminuria to nephritis 
unless there is other and more convincing evidence in the physical 
characteristics of the urine and in the other organs of the patient. 
If the twenty-four-hour amount and the specific gravity are approx- 
imately normal, and if the patient shows no oedema, no cardiac hy- 
pertrophy, no ursemic manifestations, and nothing alarming in the 
sediment of the urine, we should not diagnose nephritis. I shall 
discuss this point further in the section on the examination of the 
sediment (see page 429). It will be noted that practically all the 
types of albuminuria not due to nephritis are transient, while, with 
the exception of certain stages of chronic interstitial nephritis, the 
albuminuria of nephritis is as permanent as the nephritis itself. 

IV. Glucosuria and Its Significance. 

For glucose in the urine we need but one qualitative and one 
quantitative test, viz., Fehling's test and the fermentation test. 

1. Fehlincfs Test. — Mix in a test tube equal parts of a standard 
solution of copper sulphate x and a standard solution of alkaline tar- 
tartes, 2 and add to this mixture an equal amount of urine. Mix 
and heat nearly to boiling. The amount of error entailed by boil- 
ing is slight and unimportant, but the only advantage of boiling is 
a slight saving of time. If sugar is present a yellow or reddish- 
yellow precipitate occurs, either at once or (if the amount of sugar 
is very small) after the urine has cooled. Fehling's solution may 
also be used for quantitative estimation of sugar, but it is more 
convenient to use : 

1 Made by dissolving 34.64 gm. pure CuS0 4 in water and then adding 
enough water to make 500 c.c. 

2 Made by dissolving 173 gm. Rochelle salts and 60 gm. sodic hydrate eaeh 
in &00 c.c. of water, mixing the two solutions, and adding water to make 
500c.c. 



THE INTESTINE, SPLEEN, KIDNEY. 427 

2. The Fermentation Test. — Take the specific gravity of the 
urine as carefully as possible. Pour six or eight ounces of urine 
into a wide-mouthed vessel and crumb into it half a cake of fresh 
Fleischmann's yeast. Set the flask aside in a warm place, and after 
twenty-four hours test the supernatant fluid with Fehling's solution 
as above; if sugar is still present fermentation must be allowed to 
go on twenty-four hours longer. As soon as a negative reaction to 
Fehling's has been secured (whether in twenty-four or forty-eight 
hours), the specific gravity of the filtered urine is again taken. It 
will be found lower than before the fermentation, and for every 
degree of specific gravity lost we may reckon that 0.23 per cent of 
sugar has been fermented out of the urine. Thus if the reading 
was 1.040 before fermentation and 1.020 afterward, we multiply 
the difference between these readings, 20, by 0.23, giving 4.6 per 
cent — the percentage of sugar. 

Fehli?ig , s test should be applied to every urine examined ; it takes 
but a minute or two. When it shows a yellow or red precipitate, the 
fermentation test should also be tried ; and if both tests are positive 
we shall run but a negligible risk in saying that glucose is present. 
From the result of the fermentation test and the twenty-four-hour 
amount of urine, we can estimate the daily output of sugar through 
the urine. 

Permanent glucosuria means diabetes mellitus. Transitory glu- 
cosuria may be due to a great many causes, among which are : (1) 
Diseases of the liver; (2) diseases of the brain, organic or func- 
tional, especially the latter; (3) infectious fevers; (4) poisons, es- 
pecially narcotics (alcohol, chloral, morphine) ; (5) pregnancy; (6) 
exophthalmic goitre. 

Experimental (" alimentary ") glucosuria can be produced in 
many of these same diseases by giving the patient 100 gm. of glu- 
cose in solution. 

The differential diagnosis of the cause of glucosuria depends on 
the recognition of one of the above conditions. 



428 PHYSICAL DIAGNOSIS. 

V. The Acetone Bodies. 
Acetone, Diacetic and Beta-Oxybutyric Acids. 

1. Test for Acetone. — To about one-sixth of a test tube of urine 
add a crystal of sodium nitroprusside, and then NaOH to strong 
alkalinity. Shake and add to the foam a few drops of glacial acetic 
acid. A purple 'color shows acetone. 

2. Test for Diacetic Acid. — A Burgundy red color when a strong 
aqueous solution of ferric chloride is added to fresh urine (not pre- 
viously boiled) in a test tube. If this reaction is well marked beta- 
oxy butyric acid is probably also present, but we possess no clinical 
test for the latter substance. 

Significance of the Acetone Bodies. — Diminished utilization of 
carbohydrate food by the body appears to be the cause of the ap- 
pearance of these bodies in the urine. This may occur: (&) Because 
sufficient carbohydrates are not eaten (starvation, rectal alimenta- 
tion, fevers, etc.). (b) Because they are not absorbed (vomiting, 
diarrhoea, etc.). (r) Because they are not assimilated (diabetes). 

VI. Other Chemical Tests. 

The information to be derived from testing for indican, for the 
amounts of urea, uric acid, chlorides, phosphates, and sulphates, 
does not seem to me sufficient to justify the time spent. The same 
is true of the diazo reaction. 

Simon's lucid arguments for the value of the indican test have 
not been borne out by my experience with it in diagnostic puzzles. 
The tests for urea and uric acid are of vahie only when we possess 
a knowledge of all the factors governing their excretion, knowledge 
which in clinical work we almost never have. Diminution or ab- 
sence of the urinary chlorides in pneumonia is not constant, and 
occurs in many other infections (typhoid, scarlet fever, etc.). The 
diazo reaction is nearly constant in typhoid, but is occasionally 
found in so many other febrile and cachectic states that most clini- 



THE INTESTINE, SPLEEN, KIDNEY. 429 

cians have ceased to rely on it. Its value in the prognosis of 
phthisis is slight. I believe that the general abandonment of the 
tests for the sulphates and phosphates will soon be followed by the 
abandonment of the tests for urea, uric acid, indican, and the chlo- 
rides. The use of these tests gives the appearance of accuracy and 
scientific method in diagnosis — the appearance, but not the reality. 

VII. Microscopic Examination of Urinary Sediments. 

Methods. — A centrifuge is convenient, but not necessary. The 

sediment should be allowed to settle in a conical glass (see Fig. 

191), whence a drop of it can be transferred to a slide by means of 

a pointed glass pipette. Close the upper end of this 

with the forefinger and introduce the pointed end into 

the densest portion of the sediment ; next very slightly 

relax the pressure of the forefinger until urine and 

sediment flow into the lower one-half or three-fourths 

inch of the pipette. Then resume firm pressure with 

the forefinger, withdraw the pipette, wipe the outside 

of it dry, put its point upon a microscopic slide, and fiu. 19i.— u* n- 

again slightly relax the pressure of the forefinger so "; aI Glas ^ r ° r 
& J v r & Urinary Sedi- 

as to let a small drop of urine and sediment run out ments. 
upon the slide. Cover this drop with a seven-eighths 
inch cover glass, and examine it with a Leitz objective No. 5 or 
Zeiss DD. 

The arrangement of the light is most important. The iris dia- 
phragm should be closed until one can just distinguish the outlines 
of the cells and other objects in the field. If more light is ad- 
mitted the pure hyaline casts will be invisible. 

Results. — The objects of chief importance in the sediment are : 
(a) Casts; (b) cells; (c) crystals; (d) animal parasites or their 
eggs. 

1. Casts. — Casts, or moulds of the renal tubules, may be homo- 
geneous and transparent (hyaline, Fig. 192, 1) or may have attached 
to this matrix a variety of granules, cells, crystals, or fat drops. 
According to the variety of passengers carried down from the kid- 




430 



PHYSICAL DIAGNOSIS. 



ney on the casts, we call them granular, brown-granular, cellular, 

blood, fatty, or crystal- 
bearing casts (see Fig. 

192, 2 and 3, and Fig. 

193, 1, 2, 3, and 4). 
Dense or highly re- 

fractile casts, colorless 
or straw colored, are 
occasionally seen, and 
are often given a va- 
riety of names quite 
unjustified by any 
knowledge of their 
composition {e.g., 
" waxy,' 7 1 " fibrinous," 




Fig. 192.-Casts. 1, Hyaline casts; 
with cells and blood adherent ; 



and 3, hyaline casts 
i, "cylindroids." 



m 

SB 



etc.). 

From strands of 
mucus, foreign bodies, and other sources of error, true casts ma}' 
be distinguished by the fol- 
lowing traits : 

(a) Their sides are par- 
allel. 

(b) One end is rounded; 
sometimes both ends. 

Red corpuscles and other 
cells upon casts are to be rec- 
ognized — the former by the 
size, shape, and, if fresh, by 
their color (pale straw) ; the 
latter by the presence of a 
nucleus. 

Fat drops are spherical 

Fig. 193.— Casts, t, "Blood-casts; 2, fatty casts; 3, 
1 Some dense, ref ractile casts granular casts ; U, cellular casts, 

give the amyloid reaction, but 

this does not indicate amyloid kidneys and has no known clinical signifi- 
cance. 








THE INTESTINE, SPLEEN, KIDNEY. 431 

and very highly refractile, so that they seem to have a black line 
at their periphery. 

Crystals can be recognized by their angles. They are of no im- 
portance. 

Other bodies on casts are called granules. 

Significance of Casts. — Casts may occur in health (unless we 
choose to class muscular fatigue as disease) as well as under any of 
the conditions giving rise to albuminuria (see page 425). They are 
usually more numerous in nephritis than in most other conditions. 
Any type of cast may occur in any type of nephritis, but 

Cellular, 1 blood, and brown-granular casts are most often found 
in acute nephritis. 

Fatty, highly refracting, or dense casts most often predominate 
in chronic glomerular nephritis (" diffuse " or " parenchymatous " 
nephritis). 

Hyaline and granular casts may occur in any type of nephritis 
and in many other conditions (fatigue, renal stasis, etc.). In the 
urine of persons over fifty years of age the presence of a few hya- 
line and granular casts has no known clinical significance, and may 
probably be considered physiological. 

Periods occur in the course of many cases of chronic interstitial 
nephritis when no casts can be found. If any occur they are usually 
of the hyaline and fine granular types. 

2. Free Cells in Urinary Sediment. A. Recognition. — The pres- 
ence of macroscopic pus or blood already alluded to may be veri- 
fied by the microscope. 

(«) Fresh red cells, lately freed from the blood-vessels, preserve 
their straw-yellow color. Their presence points to the recent effu- 
sion of blood, probably from the bladder, urethra, or renal pelvis. 

(I)) Abnormal blood, decolorized and shadowy red discs, can be 
recognized with practice by their size and shape. We may infer 
that they have remained some time in the urine and have probably 
come from the kidney. 

1 " Cellular " is a better term than "epithelial," since we have no marks for 
recognizing renal epithelium or for distinguishing a renal cell from a lym- 
phocyte. 



432 



PHYSICAL DIAGNOSIS. 



," 



r 



<r 



>?. 



(c) Pus is easily recognized as a rule by the presence of the 
familiar polymorphous nucleus in most of the cells. Should doubt 
arise, a drop of dilute acetic acid allowed to run 
under the cover glass will sharpen the outlines 
of the nuclei and facilitate their recognition. 

(d) Spermatozoa (see Fig. 194) are often seen 
in the urine after coitus or nocturnal emissions. 
They are of no importance, except that when 
appearing in the urine of females they may afford X ^^y ( O 
valuable medico-legal evidence. They are easily • P \ 
recognized by their size and shape. fig. i94.-s P ermatozoa. 

(<?) Other varieties of cells need not be differ- 
entiated, since almost any of the varieties usually described (squa- 
mous, spindle-shaped, caudate, etc. ) may come from any part of the 
urinary tract. Renal cells are not recognizable by our present 

methods of examination. 

Any of the urinary cells 
may contain fat drops, but these 
have no special diagnostic sig- 
nificance. 

B. Interpretation. — The 
significance of large quantities 
'l\,^^6ffl7%-.& $ of blood or of pus in the urine 
&I"* 'jt'$A , °'$0i nas already been discussed 
(page 421) . When recognizable 
only by the microscope they 
have no diagnostic value. 

The presence of large num- 
bers of cells not coming from 
the blood-vessels (squamous, 
spindle-shaped, etc.) is usually 
associated with cystitis, pro- 
vided the accidental admixture 
of vaginal detritus is excluded. Pyelitis and renal suppurations 
may fill the sediment with similar cells, and only by other methods 
of examination (cystoscopy, ureteral catheterization) and by tak- 




Fig. 195.— Crystals of Triple Phosphate (prisms) 
and Ammonium Urate (small spheres with 
spines) . 



THE INTESTINE, SPLEEN, KIDNEY. 



433 













ing account of all the facts in the case can the differentiation be 
made. 

3. Crystals hi Urinary Sediments (see Figs. 195, 196, and 197). 

—The varieties oftenest seen 
are : (a) Triple phosphate 
(amnion iacal urine, cystitis) ; 
(Jj) ammonium urate ; (c) 
uric acid; (d) calcic oxal- 
ate. 

All of these varieties are 
colorless except the uric-acid 
crystals, which are usually 
light or dark yellow or yel- 
lowish-brown. 

None of these have much 
significance in diagnosis. 
The first two merely confirm 

Fig. 196.- Crystals of Uric Acid (whetstone-shaped) £ ne evidence of urinary de~ 
with Calcic Oxalate (small octahedral) and Amor- J 

pnous urates. composition (usually from 

cystitis) afforded by the re- 
action, turbidity, and odor of the urine. 

Uric-acid crystals, if present in great numbers in the urine when 
passed, suggest the search for 
macroscopic masses (gravel) 
and for other evidence of renal 
stone, but as a rule they are of 
no importance. 

The same may be said of 
calcium oxalate. Oxaluria is 
one of the most persistent bug- 
bears of the medical profes- 
sion, but it is utterly harmless 
except in the rare cases in which 
it accompanies macroscopic 
gravel and points to renal stone. 

4. Animal parasites or their eggs are occasionally found in the 

28 




Calcic Oxalate Crystals. 



434 



PHYSICAL DIAGNOSIS. 



urine, with or without hematuria and evidence of cystitis (see Figs. 
198 and 199). 







w 



§\ 



K\., % 






^ 



IV* 




</ 



Fig. 198.— Vinegar Eels in Urine. (Billings.) a, Protruded hooks of male; b, top-shaped 
oesophageal enlargement. The Strongyloides stercoralis (see above, Fig. 187, page 410) 
has also been found in the urine. 



Summary of the Urinary Pictures Most 'Useful in Diagnosis. 

Aside from polyuria, oliguria, hematuria, and pyuria, which 
have already been discussed, the most important conditions in 
which the urine gives valuable diagnostic evidence are : 



THE INTESTINE, SPLEEN, KIDNEY 



435 



1. Cystitis. — Urine passed frequently, painfully, and in small 
amounts. Turbid, ammoniacal, and offensive (after the earliest 
stages). Much pus and many other cells are found in the sedi- 



173 





, o 



5 / / . 



a 




Fig. 199.— Bilharzia Eggs in the Urine, with Blood, Calcic Oxalate, and a Hyaline Cast. (O'Neil.) 



ment, with bacteria, triple phosphate crystals, and amorphous 
debris. 

2. Acute Nephritis (or acute exacerbations in chronic cases). — 
Scanty, heavy, highly albuminous urine, often bloody and contain- 
ing in the sediment much blood and many cells, free or on casts. 
Other varieties of casts occur, but are not characteristic. In con- 
valescence the urine becomes abundant and of light weight, and 
the other abnormalities gradually disappear. 

3. Chronic Glomerular Nephritis ("parenchymatous "). — The 
urine is rather scanty, pale, and of light weight (1.012-1.018,) with 
a large amount of albumin and, in the sediment, much fat — free, 



436 PHYSICAL DIAGNOSIS. 

in cells, and on casts. Also found, but not characteristic, are all 
the other varieties of casts. If death does not ensue within eigh- 
teen months, the urine is apt to assume the characteristics of the : 

4. Contracted kidney (primary, secondary, or arterio-sclerotic), 
with polyuria (often several quarts; urine especially abundant at 
night), low specific gravity (1.010 or less). Traces of albumin and 
a few hyaline and granular casts occur steadily or intermittently. 



CHAPTER XXL 

THE BLADDER, RECTUM, AND GENITAL ORGANS. 
The Bladder. 

Incidence of Bladder Disease. 

(Massachusetts General Hospital, 1870-1905.) 

Cystitis 829 cases. 

Stone 538 " 

Cancer 57 " 

Papilloma 20 " 

Tuberculosis 43 " 

Data. 

Distention, tumor, the urine, and the results obtained by cystos- 
copy, by catheterization, and by sounding for stone furnish most of 
our direct evidence in bladder disease. Pain in the bladder or near 
the end of the penis, and frequent, painful micturition with vesical 
tenesmus or straining, are common symptoms in various lesions of 
the organ, and direct our attention to it, though they do not indi- 
cate the nature of its trouble. 

/. Distention of the Bladder. 

In the male, distention is often wholly unknown to the patient, 
and may be accompanied by frequent acts of urination, especially 
in prostatic obstruction. A distended bladder is readily recognized 
by palpation as a smooth, round, firm, symmetrical tumor in the 
median line, above the pubes. The tumor is dull on percussion, and 
in slight degrees of distention this dulness above the pubes may be 
the only physical sign obtainable. In marked cases, which are al- 
most invariably in males, the distended bladder may reach to the 
navel or even above it ? and the beginner is usually astonished at its 



438 



PHYSICAL DIAGNOSIS. 



dimensions and its firm, resistant surf ace (see Fig. 200). Diagnosis 
rests on the infrequency of other tumors of this region in men and 
on the result of catheterization or suprapubic aspiration. In females 
a history of failure to pass urine almost invariably makes the diag- 
nosis obvious, though occasionally after operations distention of the 
bladder and dribbling of urine may go together in women, as they 
so frequently do in men. 

The commonest causes of distended bladder are : 

(1) Prostatic hypertrophy, alone or combined with 

(2) Old strictures of the urethra. 
Less common are : 

(3) Spasm of the urethra in gonorrhoea. 

(4) Acute prostatitis. 

(5) Paralysis of the bladder, from disease or injury, after opera- 
tion, and in fevers. 

(6) Tumor or stone near the neck of the bladder. 

The diagnosis of the cause of distention rests on the history, the 

result of attempts at catheteriza- 
tion, the rectal examination, the 
condition of the urine, and the phy- 
sical signs in other parts of the 
body. A long history of frequent 
micturition, especially at night, in 
an old man, an obvious enlarge- 
ment of the prostate felt by rectum, 
and the passage of ammoniacal 
urine suggest prostatic obstruction. 
The information obtained during 
the passage of a catheter usually 
clinches the diagnosis. 

Acute retention , with no previous 
history of frequent micturition or foul-smelling urine in a young or 
middle-aged man, who has had gonorrhoea and may or may not 
have noticed a diminution in the size of the stream of urine passed, 
suggests a urethral stricture. The catheter decides. 

Spasm of the urethra may occur in acute gonorrhoea, and pro- 




Fig. 200.— Distended Bladder Reaching 
Above the. Navel. 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 439 

duces a retention which may often be overcome by hot poultices and 
enemata. The history and the effects of treatment suggest the 
cause of the retention. 

Acute prostatitis, as a cause of retention following gonorrhoea, 
is suggested by pain and tenderness in the perineum, painful defe- 
cation, fever, perhaps chills, and a hot, tender prostate felt by rec- 
tum. Abscess may form and discharge by urethra or rectum. 

Paralysis of the bladder, as a cause of retention, is usually obvi- 
ous from the history and from the evidence of disease of the spinal 
cord, or of operation and semicomatose states (as in fevers and 
shock). 

Tumors of the bladder are suggested by intermittent hsematuria 
with vesical irritation, and confirmed by cystoscopic examination. 

II. The Urine as Evidence of Bladder Disease. 

This has been described above (page 435). Cystitis, acute or 
chronic, usually gives characteristic evidence of itself in the urine, 
and suggests thereby the possibility of gonorrhoea, of vesical stone, 
of prostatic or other obstruction to the outflow, and of vesical tu- 
berculosis. When a urine like that of chronic interstitial nephritis 
occurs with chronic prostatic obstruction, the relief of the obstruc- 
tion is necessary if we are to prevent progressive development of 
cirrhotic kidney from back pressure. 

Frequent micturition is much commoner and less significant in 
women than in men. All sorts of " nervousness " and emotional 
strain produce this symptom in women, independent of any demon- 
strable source of irritation in the urinary tract. Aside from these 
conditions the symptom is oftenest met with in : 

(«) Cystitis, with characteristic changes in the urine. 

(&) Prostatic obstruction, with evidence of retention. 

(c) Gonorrhaia, with evidence of this disease. 

(d) Paralysis of the bladder (see above). 

(e) Over concentration of the urine (estimated by the color and 
specific gravity). 

III. Stone in the Bladder. — Pain near the end of the penis, espe- 



440 PHYSICAL DIAGNOSIS. 

cially at the end of micturition and aggravated by jolting or active 
motion, frequent urination, especially in the daytime, sudden inter- 
ruption of the stream of urine, and hsematuria at the end of micturi- 
tion, are the most frequent symptoms of stone, especially if they 
occur in boys. In old men stone may be wholly without character- 
istic symptoms, and at any age the symptoms can never do more 
than suggest the possibility of stone and the advisability of search- 
ing for it systematically with a proper sound. 

IV. Tuberculosis of the Bladder. — Cystoscopy and the recogni- 
tion of tubercle bacilli by animal inoculation are the only reliable 
means of diagnosis. A chronic cystitis in a young or middle-aged 
person, especially with an acid urine, is suggestive. 



The Rectum. 

It is not and should not be a part of routine physical examina- 
tion to examine the rectum. The commonest conditions which call 
for such investigation are : 

(a) Hemorrhage at stool. 

(b) The protrusion after defecation of something which is not 
easily returned (" piles "). 

(c) Painful defecation or pain in the region of the rectum at 
other times. 

(d) The presence of an ulcer or sinus near the rectum. 

(e) Habitual constipation, not explained by lesions elsewhere. 
(/) Intestinal obstruction. 

(g) Suspected appendicitis. 

(Ji) Suspected prostatitis, prostatic tumor or obstruction, or dis- 
eases of the seminal vesicles. 

(i) Pelvic symptoms in women with tight hymen. 

The diseases of the rectum which we are especially on the look- 
out for are: (1) Hemorrhoids; (2) fissure of the anus; (3) ischio- 
rectal abscess; (4) fistula in ano; (5) cancer of the rectum. Less 
common are: (6) pruritus ani; (7) prolapse of the rectum; (8) 
ulceration or stricture of the rectum, 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 441 



Methods. 

For most examinations the finger suffices. It should be covered 
by a thin, rubber finger-cot, greased with vaseline, and should be 
introduced slowly and gently while the patient strains down as dur- 
ing defecation. 

The examining finger should note the presence of abnormal 
prominences or resistance (piles, tumors) in any part of the rectum, 
of tender spots (ulcer, abscess), and strictures. The shape and size 
of the prostate gland, its consistence, and the presence or absence 
of tenderness in it are of importance. The normal seminal vesicles 
can be felt if distended. If they are hard and nodular, tuberculosis 
should be suspected. 

High up on the right side the finger may touch a tender spot if 
an inflamed appendix is near the pelvic brim. 

In women the uterus, especially if retroverted, may be easily 
felt, and most of the other details of pelvic examination (see below, 
page 447) can be more or less clearly made out. 

For higher and more thorough examination a cylindrical specu- 
lum and a head mirror should be used, with the patient in the 
knee-chest position. 

Hemorrhoids. — The diagnosis of external hemorrhoids, which 
can easily be brought outside the anus, is made at a glance. Inter- 
nal hemorrhoids are best seen with a rectal speculum, and may re- 
semble the external or may consist of " bright red, spongy, granular 
tumors, rarely larger than a ten-cent piece, and situated high up in 
the rectum " (ncevoid piles) . 

Fissure of the amis is often connected with a small ulcer and 
with oedematous folds, which resemble an external pile but are 
much more tender. On separating these folds the fissure comes into 
sight. It produces severe pain during and after defecation. 

Ischio-rectal abscess presents near the anus the ordinary signs of 
abscess, but may open either within or outside the rectum and re- 
sults in 

Fistula in ano, which is a sinus beside the rectum, opening in- 



442 PHYSICAL DIAGNOSIS. 

ternally, externally, or in both directions. It may be very tortuous 
and need examination with speculum and probe. Tuberculosis is 
always to be suspected in such fisturee. 

Cancer of the rectum is suggested by the occurrence of rectal 
pain during defecation, with blood in the stools and alternating 
diarrhoea and constipation, usually with some pallor and emacia- 
tion, in persons past middle life. Owing to neglect of a thorough 
examination many cases are at first mistaken for piles. 

The examining finger reaches a hard, ulcerating mass high up, 
as a rule, in the rectum. It may be easier to reach if the patient 
stands or squats and strains down during examination. 

From tuberculous or benign stricture with or without ulceration, 
and from benign villous growths, it may be impossible to distin- 
guish cancer without histological examination of an excised piece. 
Tumors of the prostate are always on the anterior wall of the rec- 
tum and practically never ulcerate. 

The Male Genitals. 

Routine examination of the male genitals includes investigation 
of the penis for the presence of : 

(a) Urethral discharge and its consequences. 

(b) Chancre. 

(c) Chancroid 

(d) Balanitis. 

(e) Phimosis or paraphimosis. 
(/) Periurethral abscess. 

(g) Malformations. 

(h) Cancer. 

In the testes and scrotum we look for : 

(a) Epididymitis (gonorrheal or tuberculous). 

(b) Orchitis (traumatic, syphilitic, tuberculous, after mumps and 
other infections). 

(c) Tumors of the testis (cancer or sarcoma). 

(d) Hydrocele and hematocele. 

(e) Varicocele. 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 443 

(/) Scrotal hernia. 

(g) Absence of one or both testes. 



The Penis. 

Urethral discharge, if not obvious, may often be brought to light 
by " stripping " the urethra forward from the prostatic region to the 
meatus. If Gram's stain brings out an intracellular, decolorizing 
diplococcus in the exudate, there is no reasonable doubt of the pres- 
ence of gonorrhoea. 

Chancre ("hard sore"), the primary syphilitic lesion, is a super- 
ficial, painless, indolent ulcer with an indurated base and a scanty 
serous discharge. It is usually round or oval and sharply demarked 
from the surrounding tissue by elevated edges. It is rarely multi- 
ple. Painless, hard, non-suppurating buboes accompany it. The 
glans and the inner surface of the prepuce are the commonest sites. 

Chancroid ("soft sore") is like any other painful, superficial 
ulcer without induration, irregular in shape, often multiple, and 
with abundant discharge. A single, painful bubo accompanies it in 
about one-third of all cases. 

Balanitis (inflammation of the surface of the glans penis), usu- 
ally gonorrhceal, has the ordinary signs of inflammation; it often 
spreads to the inner surface of the prepuce. 

Phimosis is a contraction of the orifice of the prepuce, so that it 
cannot be retracted to uncover the glans. May be hereditary or 
the result of gonorrhoea. 

In paraphimosis the prepuce is caught behind the glans penis so 
that it cannot be brought forward. Great oedema of the neighbor- 
ing parts usually results. 

Peri-urethral abscess, usually a complication of gonorrhoea, ap- 
pears as a small, tender swelling on the under surface of the ure- 
thra. 

Malformations are chiefly hypospadias or congenital deficiency of 
some portion of the lower wall of the urethra, and epispadias (rare), 
a similar deficiency in the upper wall. A short, downward curved 
penis is often associated with hypospadias. 



444 PHYSICAL DIAGNOSIS. 

Cancer of the penis attacks the foreskin or the glans, and has 
the usual characteristics of epithelioma elsewhere. 

The Testes and Scrotum. 

Acute epididymitis, usually a complication of gonorrhoea, appears 
as a hot and tender swelling behind the testis, often preceded by 
tenderness along the spermatic cord. Acute hydrocele may accom- 
pany it. 

Chronic epididymitis, usually tuberculous, is painless and insid- 
ious in onset, and produces a hard, irregular enlargement low down 
behind one or both testes, to which, however, the process is apt 
soon to spread. Caseation and involvement of the skin later pro- 
duce a suppurating sinus, which is often the first thing to bring the 
patient to a physician. 

Acute orchitis is often due to a blow, to gonorrhoea, or to mumps. 
The testis is symmetrically swollen and tender, but suppuration 
rarely follows. 

Chronic orchitis, often syphilitic, is slow, painless, and may be 
accidentally discovered as a slightly irregular induration of the 
testes with little if any increase in size. Ulceration and fistulse are 
rare in the syphilitic form, common in the tuberculous. 

Cancer of the testis may appear at any age. It is soft, almost 
fluctuating, and grows very rapidly, soon involving and perforat- 
ing the skin, so as to produce an offensive, fungous, granulating 
outgrowth which easily bleeds. The inguinal glands are involved. 

Sarcoma of the testis, commonest at puberty, produces a painless, 
uniform enlargement, and may reach great size. It may resemble 
hydrocele or hematocele and be mistaken for the latter, especially 
for an old effusion in a thickened sac (see below). 

Diagnosis depends on rapid growth, the entire absence of trans- 
lucency, the tendency to adhere to the skin and to present unequal 
resistance in different portions (Jacobson). Incision should be 
made in all doubtful cases. 

Hydrocele, an accumulation of serous fluid in the tunica vagi- 
nalis, may depend on trauma or on an acute epididymitis or orchi 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 445 

tis, but is usually chronic and of unknown cause. It may be con- 
genital and communicate with the peritoneal cavity or form part of 
a general dropsy in heart or kidney disease. 

Examination shows a smooth, tense, fluctuating tumor, without 
impulse on cough, usually without pain, tenderness, or any sign of 
inflammation, and, above all, translucent if examined with a hydro- 
scope tube or in a dark room with a candle. 

If the fluid is opaque or bloody, or if the tunica is thickened, 
there may be no translucency and diagnosis may be impossible 
without puncture. The testis lies behind the effusion and near its 
lower end. 

Hematocele usually follows injury and produces a heavy, opaque, 
non-fluctuating tumor, which may closely resemble sarcoma unless 
the history and evidence of trauma are clear. Incision or puncture 
should decide. 

Varicocele, an enlargement of the veins about the spermatic cord 
and vas deferens, is easily recognized as a mass of tortuous, worm- 
like vessels, generally in the left side of the scrotum. 

Scrotal hernia is usually reducible, tympanitic on percussion, 
and gives an impulse on coughing. If it consists largely of omen- 
tum it will be dull on percussion. The history of the case and the 
progression of the tumor from above downward usually make its 
origin clear. 

Absence of one or both testes from the scrotum should direct our 
search upward to the inguinal canal, since a retained testis may be 
the seat of troublesome inflammation or of malignant disease. (For 
examination of the seminal vesicles, see the Rectum, page 441.) 

The Female Genitals. 

Methods. 

Inspection of the external genitals is easy if the parts are prop- 
erly exposed by a satisfactory position and a good light. Intra vag- 
inal inspection needs a speculum (Sims' bivalve) and usually an 
assistant to hold it. 



446 PHYSICAL DIAGNOSIS. 

Palpation should always be bimanual, the left forefinger in the 
vagina (or in the rectum if the hymen is narrow), the right hand 
above the symphysis pubis. The proper co-operation of the hands 
is hard to describe and depends on practice. The pressure of the 
external hand helps to bring the pelvic organs within reach of the 
examining finger in the vagina. Unless the organs can be thus 
grasped or balanced between the outer and inner hands, no satisfac- 
tory examination is possible. Tenderness may prevent this or ren- 
der an anaesthetic necessary, but gentleness and the avoidance of 
any sudden or rapid motions do much to facilitate the examination. 
The left hand, in making its way into the upper parts of the vagi- 
nal vault, should press only on the perineum, avoiding the region 
of the clitoris. It is astonishing how much pressure can be borne 
without pain, provided it is exerted gradually and upon the peri- 
neum only. Many examiners find it advantageous to rest the left 
foot upon a stool, with the left elbow on the knee. 



Lesions. 

I. In the external genitals one looks for some of the same 
lesions already described on page 442, viz. , chancre, chancroid, local 
inflammations, and tumors. Only the commonest and most impor- 
tant lesions will be mentioned here. 

(a) In young children a suppurating vulvo-vaglnitis, usually 
gonorrheal, but non-venereal, is easily recognized by the abundant 
purulent discharge. 

(b) Local eczema, often red and angry, is commonly the result 
of the irritation of diabetic urine. 

(c) Varicose veins and oedema of the vulva are common in preg- 
nancy and occasionally result from large pelvic tumors. 

(d) Ruptured perineum, with more or less protrusion of the vag- 
inal walls, carrying with it the bladder (cystocele) or rectum (recto- 
cele), is readily recognized if the normal anatomy of the parts is 
familiar. 

(e) The hymen may be imperforate with retention of menstrual 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 447 

fluid, or tender, irritated remains of it after rupture may cause pain 
and need removal. 

(/) Urethral caruncle (a small vascular papilloma at the en- 
trance of the urethra) is a bright red excrescence, usually the size 
of a split pea or smaller. It may cause no symptoms or may pro- 
duce irritation, especially during micturition. 

(g) Small abscesses of the glands within or around the urethra 
may cause pain in coitus or during micturition. 

II. The Uterus. — Only the commonest lesions will be dealt 
with here, viz. : 

1. Laceration and "erosion" of the cervix. 

2. Malpositions of the organ. 

3. Endometritis. 

4. Cancer of the uterus. 

5. Eibro-myoma of the uterus. 

1. (a) Lacerations of the cervix following childbirth are very 
common and frequently produce no symptoms. They are readily 
recognized by inspection and palpation, and are often combined 
with: 

(b) "Erosions," an ulcerated, raw surface at and around the os 
uteri, with or without the formation of small cysts. At times the 
os assumes a warty, irregular appearance, suggesting cancer, from 
which it can be distinguished only by histological examination of an 
excised piece. 

2. (a) Malpositions (backward or forward) may involve the 
whole organ (ante- or retroversion) or represent a bending of the 
organ upon itself (ante- or retroflexion). These lesions may be va- 
riously combined and frequently exist without producing any symp- 
toms. Indeed, it is doubtful whether there is any single " normal " 
position for the uterus. Its position is recognized by bimanual pal- 
pation, which should also determine whether the uterus is freely 
movable or whether it is bound in place by adhesions, such as are 
very often found with backward displacements. 

(b) Prolapse of the uterus toward the vaginal outlet is often a 
result of pelvic lacerations unrepaired. When the uterus is outside 
the vaginal outlet, we call the condition procidentia. 



44£ PHYSICAL DIAGNOSIS. 

(c) Lateral displacement of the uterus by pressure of tumors or 
traction by old adhesions is less common. 

3. Endometritis may present no definite physical signs except a 
muco-purulent discharge (leucorrhoea, "whites") and perhaps un- 
duly frequent, profuse, or prolonged menstruation. The slightest 
touch of a uterine sound may produce bleeding. It often accom- 
panies disturbances of digestion and neurasthenic conditions, prob- 
ably as part of a general prostration rather than as its cause. 

4. Cancer of the uterus usually attacks the cervix, and in marked 
cases is easily recognized by sight and touch as a "cauliflower "- 
like, f ungating mass on the cervix. In its early stages it may be 
confounded with " erosions " and inflammatory conditions, and only 
microscopic examination can satisfactorily determine its nature. 
Profuse hemorrhage, especially in a woman about the period of the 
menopause, and the offensive odor of the discharge suggest the diag- 
nosis. The vaginal wall is soon involved in the growth, and irrita- 
bility or obstruction in bladder or rectum may result. 

5. Fibro-myoma of the uterus is by far the commonest tumor of 
that organ. It produces hemorrhages at or between the menstrual 
periods, and anaemia results. Otherwise its effects are those of 
pressure on the bladder and rectum, or on neighboring nerves or 
vessels (pain, oedema). 

Bimanual palpation determines, first of all, the fact that the 
growth is connected and moves with the uterus. This determined 
and cancer excluded by the absence of any involvement of the cer- 
vix or of the vaginal wall, the chief difficulty may be in distin- 
guishing the growth from a pregnant uterus. Usually its irregular 
shape, the persistence of menses, and the lapse of time settle the 
question. 

Lengthening of the uterine canal is an important confirmatory 
sign of fibromyoma, but sounds should never be passed to determine 
this fact unless pregnancy can be definitely excluded. 

III. Fallopian Tubes. — Salpingitis (acute or chronic) and 
tubal pregnancy are the most important diseases of the tubes.' 

(a) Salpingitis is usually gonorrhoeal, occasionally tuberculous, 
sometimes of unknown origin. A painful, tender swelling or indu- 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 449 

ration in the region of the tube, with or without fever, chill, or 
leucocytosis, constitutes the evidence for diagnosis. From pelvic 
peritonitis of the tubal region diagnosis is impossible. 

From tubal pregnancy diagnosis may be very difficult, and sus- 
picions are rarely aroused until rupture occurs (vide infra). If the 
signs and symptoms of pregnancy are absent and tenderness is 
marked, the condition is usually called salpingitis ; but even then 
mistakes often occur, as the menses may persist in tubal pregnancy 
and the foetal tumor may be tender. Only when pregnancy can 
absolutely be excluded is diagnosis sure. 

(b) Tubal pregnancy, as just explained, is rarely to**be diag- 
nosed until the growth of the foetus ruptures the tube — an event 
which usually occurs between the third and the twelfth week of 
pregnancy. 1 Sudden pelvic pain with tenderness, vomiting, and 
evidence of internal hemorrhage (i.e., pallor, fainting, weak, rapid 
pulse, thirst, air hunger) suggest the diagnosis, especially if a tumor 
in the tubal region can be detected bimanually. 

IV. Ovaries. — A prolapsed ovary is often felt during a vaginal 
examination, being recognized by its size, shape, and relation to the 
uterus. 

Ovaritis, enlargement, and tenderness of one or both ovaries is 
usually part of tubal disease and not sharply to be distinguished 
from it before operation . In other cases it is associated with cyst for- 
mation, and the cysts may be palpated bimanually. Abscess of the 
ovary is not commonly diagnosed, but is met with in operations for 
pus tubes. 

Ovarian Cystoma. 

(a) Small Tumors. — In their earlier stages these growths pro- 
duce symptoms only when complications arise, i.e., suppuration or 
twisting of the pedicle. Small, suppurating cysts give practically 

1 If disturbances of menstruation, morning nausea, changes in the breasts, 
and cyanosis of the vagina are combined with an extra-uterine tumor and an 
unusually slight uterine enlargement, the diagnosis of tubal gestation may be 
suspected prior to rupture. 
29 



450 



PHYSICAL DIAGNOSIS. 



the same signs as those of a pus tube, and are recognized only at 
operation or autopsy. 

Twisted pedicle gives rise to symptoms and signs often indistin 1 
guishable from those of intestinal obstruction. Only the recogni- 
tion of the tumor as ovarian can suggest that the acute symptoms 
may be due to twisting of its pedicle. 

(b) Large ovarian tumors have been confused in my experience 
with pregnancy j fibroid of the uterus, ascites, and tuberculous peri- 




Fig. 201.— Huge Ovarian Cyst. 



tonitis. From these we may usually distinguish an ovarian tumor 
by its history, its origin from one side of the belly, by the shape 
of the belly, the area of percussion dulness, and the pelvic examin- 
ation . 

By the history we should attempt to exclude- disease of the 
heart, kidney, and liver, and tuberculosis of any organ, should in- 
quire into the position of the tumor in the earlier stages of its 
growth, and establish the presence or absence of the ordinary signs 
of pregnancy and of uterine hemorrhages such as occur with fibroids. 

In ascites or tuberculous peritonitis the flanks often bulge (see 
Fig. 180, page 372), whereas in ovarian disease the bulging is central 
and greatest just below the navel (see Fig. 201). 



THE BLADDER, RECTUM, AND GENITAL ORGANS. 451 

If by the history or by palpation and percussion we can deter- 
mine that the tumor is fluctuant and springs from one side of the 
abdomen, it is in all probability ovarian. High psoas abscess 
sometimes presents identical signs, but is associated with evidence 
of spinal tuberculosis (see below, p. 489). Moderate ascites or tu- 
berculous peritonitis leaves an oval, resonant area about the navel, 
which is absent with large ovarian tumors ; but if the amount of 
free fluid is large, percussion and palpation may give results iden- 
tical with those found in ovarian disease. 

Vaginal examination may exclude fibroid by showing that the 
uterus is not directly connected with the tumor and by demonstrating 
with a uterine sound that the uterine canal is not elongated. 

Solid tumors of the ovary, carcinoma, sarcoma, or fibroma are 
rarely recognizable before operation and are often mistaken for pe- 
dunculated uterine fibroids. 



CHAPTER XXII. 

THE LEGS AND FEET. 

The Legs. 

I. Hip. 

The examination of the hip will be discussed later (see page 

489). 

II. Groin. 

In the groin we look for evidences of : 

1. Enlarged or inflamed lymphatic glands and scars of previous 
inflammation. 

2. Hernia and hydrocele of the cord. 

3. Psoas abscess. 
Less common are : 

4. Retained testis. 

5. Filarial lymphatic varix. 

1. Inguinal Glands. — Two sets of inguinal glands are distin- 
guished — one arranged along the lower half of Poupart's ligament; 
the other lower down, around the saphenous opening. 

(a) The "Poupart's group" are acutely enlarged in lesions of 
the genitals ("bubo" of gonorrhoea, 3 syphilis, chancroid) and peri- 
neum; chronically enlarged in malignant disease of the penis, uterus 
(late), and other genitalia. 

(b) The saphenous group is enlarged in response to lesions of the 
thigh, leg, and foot (cuts, wounds, ulcers, eczema, etc.). 

1 The bubo of gonorrhoea often suppurates ; that of syphilis rarely. Hence 
a scar in the inguinal region suggests an old gonorrhoea. 



THE LEGS AND FEET. 



453 



(c) Either or both groups may be enlarged in leukaemia, Hodg- 
kin's disease (see above, page 30), infectious arthritis, and various 
obscure fevers. In many cases no cause for enlargement can be found. 

2. Hernia is diagnosed by the presence of a soft, resonant, fluc- 
tuating, usually reducible tumor with an impulse on coughing. 
Hydrocele of the cord gives 

also an impulse on cough- 
ing, but usually shows a 
distinct limit above. On 
pulling the cord the swell- 
ing moves too. 

3. Psoas abscess (see 
Fig. 202) presents the ordi- 
nary signs of pus and is 
associated with vertebral 
tuberculosis (dorsal or lum- 
bar). 

4. Retained testis 
should be suspected when- 
ever an inguinal tumor is 
present and only one tes- 
tis is found in the scrotum. 

5. Filarial lymphan- 
giectasia is generally mis- 
taken for hernia and oper- 
ated on as such, although it gives no impulse on coughing and can- 
not be completely reduced. The history of residence in the tropics 
should always suggest an examination of the blood (at night) for 
filarise. 

III. The Thigh. 

The records of the Massachusetts General Hospital show that 
(1) epiphysitis and osteomyelitis (septic or tuberculous) are almost 
ten times as common as any other serious lesion of the thigh, except 
fracture. The cases are to be divided into acute septic eases and 
chronic, usually tuberculous, cases. 




Fig. 202.— Psoas Abscess. (Bradford and Lovett.) 



454 PHYSICAL DIAGNOSIS. 

The acute septic cases begin with severe pain, tenderness, fever, 
chill, and leucocyte-sis. Later an induration and finally fluctuation 
appear, and the abscess, if not incised, will break externally. Gen- 
eral, sometimes fatal, septicaemia may take place. 

The chronic tuberculous cases first consult the physician, as a 
rule, for sinus, which proves when explored to lead to dead bone, 
as do most of the sinuses from septic cases. 

The diagnosis of the acute cases depends chiefly on excluding 
arthritis of any type. Careful examination with testing of joint 
motions will usually demonstrate that the pain and tenderness are 
in the bone and not in the joint. The leucocyte count is but 
slightly elevated in most cases of arthritis, but is decidedly high, 
20,000 or more, in most cases of acute osteomyelitis. The same is 
true of the temperature. Monarticular arthritis — the only variety 
likely to be considered in such a diagnosis — is rare in youth, when 
most cases of acute osteomyelitis and epiphysitis occur. 

Whether the disease starts in the shaft of the bone or in the 
epiphysis is to be determined by the seat of pain and tenderness. 

Tuberculous cases can be recognized only by the histological ex- 
amination. Old cases may be suspected by the presence of a scar, 
but 

(2) Multiple white scars should always suggest, though they are 
far from proving, syphilis, for chronic ulcer above the knee is often 
due to gumma. 

Tumors of the Thigh. 

(1) Sarcoma of the femur is the commonest and largest tumor 
of the thigh. Among one hundred and thirty -three tumors of the 
thigh recorded at the Massachusetts General Hospital, sixty-six 
were sarcoma. A hard, spindle-shaped growth encircles the femur ; 
the lower end is the commonest site, but any part of the bone may 
be affected (see Fig. 203). 

(2) Osteoma, or exostosis, occurred eleven times in the one hun- 
dred and thirty-three cases just mentioned. It is much smaller and 
of slower growth. The last trait usually serves to distinguish it 
from sarcoma. 



THE LEGS AND FEET. 



455 



(3) Metastatic cancer of the upper half of the femur may occur 
after cancer of the breast, but rarely gives rise to symptoms unless 
spontaneous fracture occurs — an event which always should suggest 
cancer. Epithelioma of 

the thigh is not very rare 
(twelve cases in the one 
hundred and thirty-three 
above referred to). Its 
traits are those of epi- 
thelioma elsewhere. 

Tuberculosis of the 
knee may simulate sar- 
coma of the lower end of 
the femur, but sarcoma 
grows more rapidly. 
The tuberculin test or an 
exploratory incision may 
be necessary to decide the 
diagnosis. 

(4) Psoas abscess or 

hip-joint abscess (see Fig. 202) may burrow down so as to point on 
the thigh. The evidence of disease in the hip or vertebrae is usu- 
ally sufficient to make clear the diagnosis. 




Fig. 203.— Sarcoma of the Femur. 



Miscellaneous Lesions of the Thigh. 

(1) Phlebitis with thrombosis of a vein, usually the saphenous, 
is a common cause for swollen thigh (and leg) with pain and tender- 
ness, especially over the inflamed vein, where a corcly induration can 
often be felt. Typhoid fever and the puerperal state are the usual 
causes. Diagnosis depends on the presence of these signs and causes 
and the absence of any other demonstrable cause for inflammation. 

(2) Meralgia paraesthetica means the presence of a patch of an- 
aesthesia, paraesthesia, or hyperaesthesia (tenderness), with or with- 
out pain, on the anterior and upper surface of one or both thighs 
(the area of the external cutaneous nerve). 



456 



PHYSICAL DIAGNOSIS. 



(3) Paget' s disease (osteitis deformans) presents usually its 
most marked lesions in the legs and head, though most of the other 
bones are also affected. In the leg the most characteristic lesions 

are forward bowing of the femur 
and tibia with outward rotation 
of the whole limb (see Fig. 204). 
The #-ray shows marked thick- 
ening of some areas, with thin- 
ning of others. 

(4) Intermittent Claudication 
and " Cramps." — Insufficient cir- 
culation through the arteries of 
the legs may give rise to sudden 
" giving way n of one or both 
during running or walking, the 
power returning after a short 
rest. In patients at rest the 
frequent recurrence of painful 
cramps in the muscles may be 
the only manifestation of the 
disease. 

Obliteration of the dorsalis 
pedis (or larger arteries) by ar- 
teriosclerosis is often found, but 
there is reason to believe that 
local anaemia, due to vasomotor 
disturbances or other causes, 
may produce similar cramps 
football players during a hard run and in 




Fig. 204.— Paget's Disease (Osteitis Defor- 
mans). Note the outward and forward 
bowing of legs and arms. (Robin.) 



(e.g., those seen 
pregnant women). 



Paralyses. 



(1) Paralysis of one leg, occurring in children, is usually due 
to anterior poliomyelitis ; in adults it usually forms part of a hemi- 
plegia or is of hysterical origin. Neuritis, due to alcohol, lead, 
arsenic, or diphtheria, may affect one leg predominantly, but both 



THE LEGS AND FEET. 457 

are usually involved. Cerebral monoplegias, due to cortical lesions 
of the leg area, are rare. Chorea may be associated with a limp, 
half-paralyzed condition in one leg, usually with some involvement 
of the arm on the same side, and the characteristic motions (see 
above, page 44) make the diagnosis clear. 

The differential diagnosis of the other varieties of monoplegia is 
usually easily made with the aid of a careful history and a thorough 
examination of the other parts of the body. 

(2) Complete paralysis of both legs (paraplegia) is commonest 
in diffuse or transverse myelitis {e.g., in spinal tuberculosis or me- 
tastatic cancer with pressure on the cord), in multiple sclerosis, 
spastic paraplegia (hereditary or acquired), and in late tabes. Hys- 
teria also may produce a spastic paraplegia, though monoplegia is 
commoner in this disease. 

(3) Partial paralysis of both legs is oftenest due to neuritis, 
resulting from the causes mentioned above. The extensors of 
the foot are especially affected and toe-drop results, so that in 
walking " the entire foot is slapped upon the ground like a flail " 
(Osier). 

Differential Diagnosis. — (a) In diffuse or transverse myelitis, 
whether or not the trouble be due to pressure, there are increased 
reflexes, anaesthesia, usually loss of control of the sphincters (in- 
voluntary urine and fseces), and often bed-sores. 

(&) In spastic paraplegia of any type the legs are stiff and the 
reflexes increased, but sensation and the sphincters are normal and 
there is no atrophy or bed-sore formation. 

(c) In multiple sclerosis there are usually no disturbances of sen- 
sation or of the sphincters, and the paralysis is associated with nys- 
tagmus, intention tremor, and slow, staccato speech. 

(c£) Tabes dorsalis shows ataxia but no paralysis until late in its 
course. The paralytic stage is preceded by a long period character- 
ized by lightning pains, bladder symptoms, Argyll-Robertson pupil 
(see page 15), and loss of knee-jerks. 

(e) Hysteria may take on almost any type of paralysis and may 
deceive the very elect, but as a rule the other evidences of hysteria 
guide the diagnosis. 



458 



PHYSICAL DIAGNOSIS. 



IV The Knee. 

{a) Tuberculosis, atrophic, hypertrophic, and infectious arthri- 
tis, and traumatic synovitis are the commonest diseases, but will be 

described with other dis- 
eases of the joints (see 
page 486). 

(li) Housemai d' s 
knee is a bursitis of the 
prepatellar bursa (see 
Fig. 205). Fluctuation, 
with or without heat 
and tenderness, and 
limited to the prepatel- 
lar space, is diagnostic. 
(c) B o w - 1 e g s and 
knock-knee are so easy 
of diagnosis that I shall 
simply mention them 
here. 

V. The Lower Leg. 

1. Varicose veins, 
with their results (ecze- 
ma and ulcer), are the 
commonest lesions of 
the lower leg. The 
soft, twisted, purplish 
eminences are easily 
recognized. Hard?iessm 
such a vein usually 
means thrombosis. It 
should be remembered that pregnancy and pelvic tumors may pro- 
duce varicose veins in the legs. 

2. Chronic ulcers of the lower leg, especially those in front, are 




Fig. 205.— Prepatellar Bursitis ("Housemaid's Knee"). 



THE LEGS AND FEET. 459 

usually due to varicose veins and the resulting malnutrition of the 
tissues. They leave a brown scar after healing. Syphilitic ulcers 
usually leave a white scar ; they may occur in the same situation, 
but are more common above the knee or on the calf. 

3. Syphilitic periostitis is common on the shaft of the tibia, and 
gives rise to pain (worse at night) with tenderness and some swell- 
ing. Later bony nodes are formed, similar to those already pictured 
on the frontal bone. 

4. Osteomyelitis (acute septic or chronic tubercular) often starts 
on the head of the tibia, with intense pain, tenderness, fever, and 
leucocytosis (if acute or septic) ; there results a general septicaemia 
or a local sinus leading to dead bone. 

5. Sarcoma not infrequently attacks the upper end of the tibia 
or fibula, producing lesions similar to those described in the femur. 

6. (Edema of the legs 1 is oftenest due to : 

(a) Uncompensated heart lesions, primary or secondary from 
lung disease. 

(b) Nephritis. 

(c) Anaemia. 

(d) Neuritis (alcoholic, beri-beri, etc.). 

(e) Varicose veins. 

(/) Obesity, flat-foot, and other causes of deficient local circu- 
lation. 

In some cases no cause can be found (" angioneurotic " oedema, 
"loss of vasomotor tone "). Diagnosis of the cause of oedema de- 
pends on the history and the examination of the rest of the body. 

In one leg oedema may be due to thrombosis of a vein (see page 
455), to pressure of tumors in the pelvis (pregnancy, etc)., to hemi- 
plegia, or to inflammation. 

7. Tenderness in the lower legs frequently accompanies oedema 
from any cause. It may also be due to neuritis or trichiniasis, and, 
of course, to any local inflammation. 

1 It is notable that oedema is usually greatest in the front of the leg and in 
the back of the thigh. 



460 



PHYSICAL DIAGNOSIS. 



The Feet. 

1. The varieties of club-foot are : (a) Equinus, the heel drawn 
up. (b) Varus, the ankle bent outward, (c) Valgus, the ankle 
bent inward and the foot outward, (d) Calcaneus, the foot turned 
outward and upward. 

The affection, which is usually congenital, occasionally the result 
of contractures after paralysis, presents no difficulties in diagnosis. 



77 





- j23&* 



Fig. 206,-Flat-foot. (Bradford and Lovett.) 



2. Flat-foot is a breaking down or weakening of the normal arch 
of the foot, so that the print of the sole loses more or less of the 
normal concavity in the inner side (see Figs. 206, 207, and 208). 
There are usually pain and tenderness near the attachment of the 
ligaments and often higher up on the leg. 



THE LEGS AND FEET. 



461 



3. Tenosynovitis of the Achilles tendon often produces pain in 
the tendon, increased by use and sometimes associated with palpa- 
ble creaking or crepitus over it. 

4. Enlarged (rachitic) epiphyses are seen at the lower end of the 




Fig. 207.— Flat-foot. Print of the sole. (Bradford and Lovett. 



tibia and fibula just above the ankle-joint in about forty per cent of 
rachitic cases. The other signs of rickets in the child make diagno- 
sis easy. 

5. Tuberculosis is especially apt to attack the ankle bones in 
young persons. It is recognized by the usual evidences of joint 
tuberculosis (see below, page 492). 

6. Epithelioma of the ankle has the characteristics of epitheli- 
oma elsewhere. 



462 PHYSICAL DIA&NOSlS. 

7. Erythromelalgia, or red neuralgia of the extremities, is com* 
monest in the feet. The toes (or fingers) are red, hot, tender, and 
painful in (Kaynaud's disease the digits are cold and painless or 
anaesthetic). The attacks are aggravated by heat and not (like 
those of Raynaud's disease) by cold. Such attacks are probably 




Fig. 308.— Print of the Soles of Normal Feet. (Bradford and Lovett.) 

akin to the condition of " hot feet " often seen in arteriosclerosis and 
myocarditis. The patient kicks off the bed clothes from his feet at 
night on account of the burning sensations in them. Other evi- 
dence of insufficient arterial blood supply {e.g., clubbing, intermit- 
tent claudication, cramps, gangrene) may coexist. 



?HE LEGS AMD FEtiT. 463 



The Toes. 

Many of the lesions already mentioned in the fingers are found 
also in the toes {e.g., atrophic and hypertrophic arthritis ■, acromegaly, 
pulmonary osteoarthropathy, tuberculous or syphilitic dactylitis, 
tremors, spasms, and choreiform movements). Other lesions, such 
as ingrowing toenail, bunion, hallux valgus, policeman's heel, are 
too purely iocal to deserve description here. Excluding these we 
have left : 

1. Gout, which is especially prone to attack the metatarso-pha- 
langeal joint of the great toe, producing all the classical signs of 
inflammation. 

2. Gangrene is usually the result of arteriosclerosis with or 
without diabetes mellitus, but may result (as in the fingers) from 
arterial spasm or local asphyxia (Raynaud's disease). 

3. Perforating Ulcer. — In diabetes and sometimes in tabes a 
trophic or nutritional ulcer may develop in the toe or tarsus as a 
result of nerve influences similar to those which produce Charcot's 
joint or herpes zoster in the diseases just mentioned. It is called 
" perforating ulcer " because of its stubborn progression despite a 
plan of treatment that checks ordinary infectious abscesses. Actual 
perforation is not often seen. 

4. " Tender toes " after typhoid fever result from an infectious 
neuritis. 

5. " Morton* s disease" (metatarsalgia) means pain in the tarsus 
at a small spot near the distal end of one of the three outer toes, 
always associated Avith compression of the foot by tight boots and 
probably due to pinching of the external plantar nerves between the 
metatarsal bones. It is relieved by proper shoes. 



CHAPTER XXIII. 

THE BLOOD. 

Examination of the Blood. 

The essentials of blood examination as a part of physical diag- 
nosis are as follows : 

I. Haemoglobin test (Tallqvist in all cases). 

II. Study of a stained blood film in most cases. 

III. Total leucocyte count (Thoma-Zeiss) in many cases. 

IV. Count of red corpuscles and Widal reaction in a few cases. 

V. Coagulation time, rarely. 

I will now give a brief account of each of these methods and of 
the interpretation of the data obtained by them. 

/. Haemoglobin. 

(&) The Tallqvist scale consists of ten strips of red-tinted paper 
corresponding to the tint of a filter paper of standard quality when 
saturated with blood containing ten per cent, twenty per cent, thirty 
per cent, etc., haemoglobin up to one hundred per cent. To per- 
form the test we puncture the lobe of the ear with a glover's needle 
(not with sewing needle), saturate a strip of the filter paper which 
is bound up with the scale, in the blood of the patient to be exam- 
ined, and compare the tint of this strip with the different standard 
tints in the scale. Always saturate at least half a square inch of 
filter paper with blood and allow it to dry until the gloss has dis- 
appeared. Do not blot it, and do not delay in making the com- 
parison after the humid gloss has disappeared. Stand with the 
light behind you or at one side of you ; use daylight always. 



THE BLOOD. 



465 




The test is not accurate within ten degrees, but a degree of ac- 
curacy greater than this is very rarely required for any purpose of 
diagnosis, prognosis, or treatment. In rare cases, when a more 
accurate reading is needed, we may use the instrument of Gowers 
as modified by Sahli. 

(b) Sahli' s instrument see (Fig. 209) must be obtained from one 
of the firms recommended by him, 1 else the standard solution is 
likely to be inaccurate in col- 
or. To use the instrument 
we first put a few drops of 
water 2 into the empty tube 
(Fig. 209, B), then suck up 
blood with the pipette (Fig. 
209, C), until the mark 1 is 
reached. Wipe the point of 
the pipette and immediately 
blow out the blood into the 
water at the bottom of the 
tube (B). Suck this mixture 
of blood and water back into 
the pipette and blow it out 

again twice to cleanse the pipette. Next add water from the 
dropper (D), a few drops at a time, until the tint of the mixture 
of the blood and water is the same as that of the standard solu- 
tion, when both are looked at with transmitted light. After 
each addition of water close the end of the tube with the thumb 
and invert it twice, then scrape the thumb on the edge of the tube 
so as to rub off any moisture deposited there during the process of 
inversion. As the tint of the mixture of blood and water ap- 
proaches that of the standard solution, add the water two drops 
at a time, and close the eyes for a few seconds between each two 
attempts at reading. When the colors in the two tubes seem to be 

1 Holtz or Biichi of Berne. 

2 The description here given follows Gowers. 

Sahli — " Fill concavity of empty tube with decinormal HC1 solution." and 
blow the blood into this — then dilute with water as above. 

30 



Fig. 209.— Gowers' Hsemoglobinometer. B, Di- 
luting tube ; C, pipette ; D, dropper. 



466 PHYSICAL DIAGNOSIS. 

identical, read off the figure corresponding with the meniscus of the 
column of fluid in the tube. The resulting figure represents the 
percentage of haemoglobin. 

(c) The Color Index. — The data to be obtained by these instru- 
ments stand for the amount of the coloring matter in a given unit 
of blood when compared with the amount in a similar unit of nor- 
mal blood. When the haemoglobin percentage is low, anaemia is al- 
ways present, and the degree of anaemia is measured by the amount 
of reduction in the haemoglobin per cent. But the percentage of 
haemoglobin is not a measure of the number of corpuscles present in 
a given unit of blood, for if the corpuscles are large and contain each 
of them a relatively large amount of haemoglobin, they may be con- 
siderably diminished in number and yet furnish a normal bulk of 
haemoglobin, as tested by either of the instruments described. Thus 
in pernicious anaemia the corpuscles are often so large that they 
contain nearly one-third as much agaiii as a normal corpuscle, so 
that even though their number is considerably diminished they may 
carry a normal amount of haemoglobin. This condition is known 
as a,"7iigh color index." On the other hand, the number of red 
corpuscles may be normal, yet each corpuscle so deficient in haemo- 
globin that the haemoglobin in a given quantity of blood is as low 
as forty or fifty per cent. This state of things is often found in 
chlorosis or in any form of secondary anaemia (see below, page 475). 
When the diminution in the number of red corpuscles is greater 
than the diminution of haemoglobin, we say that the color index is 
high, meaning that each corpuscle carries more haemoglobin than 
normal. Thus if we have a red count of two millions and a half of 
red cells, and each cell contained the normal amount of haemoglobin, 
the haemoglobin percentage would be fifty, representing a reduction 
in haemoglobin proportional to the reduction in the red cells ; but if 
with the same count we had a haemoglobin percentage of seventy- 
five, this would mean that each corpuscle contained half as much 
again as compared with the haemoglobin in normal red cells. Here 
we should say that the color index is 1.5. Five million red cells 
and one hundred per cent of haemoglobin give a color index of 1 ; so 
do four million red cells with eighty per cent of haemoglobin, three 



THE BLOOD. 



467 



million and sixty per cent, two million and forty per cent, and so 
on. An example of low color index would be four million red cells 
with forty per cent haemoglobin, representing a color index of 0.5; 
or three million red cells with thirty per cent haemoglobin, repre- 
senting again a color index of 0.5. 

The diagnostic significance of the color index is briefly this : 
Any diminution in haemoglobin means anaemia, but a diminution in 
haemoglobin with a high color index suggests, though it does not 
prove, pernicious anaemia, while a low color index points to chloro- 
sis or secondary anaemia of any type. Normal color index, despite 
anaemia, is most often found immediately after hemorrhage. 



II. Study of the Stained Blood Film. 

To recognize the presence and the degree of anaemia one needs 
only the hcemoglobin test, but to determine the kind of anaemia, to 
study the leucocytes, or to search for parasites we need the stained 
blood film. Two processes are now to be described: 

1. Preparing the film. 

2. Staining. 

1. Blood films may be spread on slides or on cover glasses. The 
first method is the easier; the second gives better preparations. To 
prepare blood films on slides, 
dip two slides in water and 
rub them clean with a towel 
or handkerchief ; put a drop 
of blood near one end of 
one slide, put the other slide 
against the drop, and rest 
it evenly upon the first, as 
shown in Fig. 210. Next 
draw the upper slide along 
horizontally, so as to spread 
the drop over the whole 

surface of the lower slide. The process may then be repeated, re- 
versing the slides and using as a " spreader " the one on which the 




Gveejf/4 



Fig. 210.— Method of Spreading Blood Films. 



468 PHYSICAL DIAGNOSIS. 

film has already been prepared. This method is so simple that one 
can usually succeed with it at the first attempt, but the corpuscles 
are not spread quite so evenly as in cover-glass preparations and it 
is somewhat more difficult to get a perfect stain. 

The cover-glass method requires a much greater degree of clean- 
liness and manual dexterity than the slide method. Cover glasses 
must be washed in water and then thoroughly polished with a silk 
(not cotton or linen) handkerchief. The success of the whole proc- 
ess depends upon the thoroughness of the polishing. Every part 
of the glass must be thoroughly gone over, taking care not to omit 
the corners. This is rather tedious and often drives us to use 
slides, which can be much more quickly 
^^^-^ prepared. With cover glasses we must 

I ~ — L remove not only all dirt and grease, but 

/ |"~ ■ also every speck of dust or lint which may 

/ / ^ ^ settle upon them. The use of silk as a 

^ polisher reduces this difficulty to a mini- 

mum. 

Having prepared the cover glasses in 
this way, the next point is to keep them 

Fig. 211.— Proper Method of ■" l x 

Holding a Cover Glass. both clean and dry during the process of 

spreading the blood. We must always 
hold them as in Fig. 211, and never touch any part of their sur- 
faces with the fingers. Any one whose fingers tend to get moist 
must handle the cover glasses with forceps, but most of us will al- 
ways use our fingers, despite the warnings of our Teutonic brethren. 
Holding a cover glass as in Fig. 211, touch the centre of it with the 
tip of a drop of blood as it issues from a puncture, taking care 
not to touch the skin of the ear itself; then drop this cover glass 
(blood side downward) upon a second cover glass in such a posi- 
tion that their corners do not match. If the covers are quite clean 
and free from dust, the blood drop will at once spread so as to 
cover the whole surf ace of the glasses. The instant it stops spread- 
ing, take hold of the upper cover glass by one corner and slide it 
rapidly off without lifting it or tilting it at all. This needs some 
practice, and some men never learn it ; hence the use of slides. 






THE BLOOD. 469 

Films so prepared will keep for a long time without deteriorat- 
ing, especially if the air is excluded. 

2. Staining. — The introduction of the "Romanowsky method of 
staining (Nocht's, Ziemann's, Jenner's, Leishman's, Wright's) ena- 
bles us to dispense with all other blood stains and greatly shortens 
the time of the process. Wright's stain is identical with Leish- 
man's except in the method of preparation, which Wright has consid- 
erably simplified, and as either of these mixtures can be obtained 
ready made of any of the larger dealers in physicians' supplies, I 
shall not describe the method of making it. Reliable stains can 
always be obtained from the Massachusetts General Hospital in Bos- 
ton. An ounce bottle will stain hundreds of specimens. 

To stain a cover-glass film, grasp it with Cornet's forceps, rest 
the forceps on the sink so that the film side is upward and is ap- 
proximately horizontal. Draw a little of Wright's or Leishman's 
stain into a clean medicine-dropper and squeeze out upon the film 
enough to flood its surface. 

(a) Allow the stain to act for one minute ; during this time the 
methylic alcohol contained in it fixes the film upon the cover glass. 

(b) Next add distilled water from a clean medicine-dropper until 
a greenish metallic lustre appears like a scum upon the surface of 
the stain. Usually about six or eight drops of water are needed if 
we are using a seven-eighths-inch cover glass. The stain, so di- 
luted with water, should remain upon the cover glass about two 
minutes. The exact time does not matter. 

(c) Next wash off the stain with water cautiously and let the film 
remain in clean water for about a minute more or until it takes on 
a light pink color. Dry gently with blotting paper and mount in 
Canada balsam. 

This whole process can be completed inside of five minutes, and 
I know of no other staining method at once so rapid, so reliable, 
and so widely applicable. It brings out all the minutiae of the red 
corpuscles, leucocytes, and blood parasites, and for clinical work no 
other stain is needed. 

Appearance of Films so Stained. — 1. The normal red corpus- 
cles appear as round discs with pale centres. Their color depends 



470 



PHYSICAL DIAGNOSIS. 



upon the length of time that we continue the washing with clear 
water after the staining mixture has been poured off, and varies 
from brown through pink to golden yellow. 

(a) Poikilocytosis means the appearance in the blood of red cells 
variously deformed, sausage shaped, battledore shaped, oblong, 
pear shaped, etc. It is always associated with abnormalities in the 
size of the corpuscles, so that dwarf forms and giant forms appear. 
(6) Polychromasia (or polychromatophilia) refers to abnormal 
staining reactions in the red corpuscles, whereby isolated individ- 
uals take on a brownish or purplish tint, sharply contrasted with 
the pink or yellow of the corpuscles around. If this brownish or 
purplish tint occurs in all the corpuscles, it has no pathological sig- 
nificance, but merely means that the staining has been incorrectly 
performed. 

(c) " Stippling" refers to fine, dark-blue dots scattered over the 
pink surface of a red corpuscle, as if a charge of fine shot had been 
fired into it. 

All the abnormalities just described are to be found in any of 

the types of severe anaemia, 
whether primary or secondary, 
but stippling may also be found 
without anwmia in some cases 
of lead poisoning, and is there- 
fore useful as a confirmatory 
sign in cases of this disease. 

Nucleated red corpuscles are 
divided into two main varieties : 
(1) normoblasts, which are of 
the size of normal corpuscles ; 
and (2) megaloblasts, which are 
larger than normal corpuscles 
(see Fig. 212). The nucleus 
of the normoblast is generally 
small and deeply stained, navy 
blue. In the megaloblast the nucleus may have the same charac- 
teristics or may be much larger and paler, with a distinct intranu- 




Fig. 212.— Nucleated Red Cells, m, m, Megalo- 
blasts ; ??, normoblast; s, stippled cell. 



THE BLOOD. 



471 



clear network. The protoplasm of both varieties is often discol- 
ored, murky, gray, or even blue, and sometimes stippled, so that 
by beginners the cell may be mistaken for a leucocyte. The mis- 
take may be avoided, however, after some experience. In the pro- 
toplasm of nucleated cells 
there are often concentric 
rings like the layers in an 
oyster shell, and their outline 
is usually more irregular than 
that of any leucoctye. Fur- 
ther points of differentiation 
must be learned by practice. 

2. Leucocytes. — In normal 
blood four main varieties may 
be distinguished : 

(a) Polynuclears or poly- 
morphonuclear neutrophiles. 

(b) Lymphocytes (large 
and small). 

(c) Eosinophiles. 

(d) Mast cells, 
(a) Polynuclears. — ■ The 

deeply stained, markedly con- 
torted nucleus assumes a great 
variety of shapes in different 
cells, and is surrounded by a 
pinkish protoplasm studded 
with spots or granules just 
large enough to be distin- 
guished under the oil immer- 
sion and slightly deeper in 
tint than the protoplasm 
around them. These cells 
make up about two - thirds 
(sixty to seventy per cent) of 
all the leucocytes present in the blood (see Fig. 213, a). 




Fig. 213.— a, Leucocytosis (40,000) ; sixteen polynu- 
clears in a field. 5, Lymphatic leukaemia, p, 
Polynuclear; m, megaloblast; e, eosinophile. 
Twenty-one lymphocytes in this field. 



•472 PHYSICAL DIAGNOSIS. 

(b) Lymphocytes. — The smallest variety is about the size of a 
red cell, and consists of a round nucleus stained deep blue and sur- 
rounded by a very narrow rirn of pale, bluish-green protoplasm. 
In the larger forms the nucleus occupies much less space relatively, 
is often less deeply stained, and may be indented. The latter vari- 
ety is sometimes burdened with the useless name of " transitional 
cell," a term which in my opinion should be given up, since all 
lymphocytes are transitional. In the protoplasm of the larger vari- 
eties of lymphocyte one often sees a sprinkling of fine pink gran- 
ules. From twenty-five to thirty-five per cent (or about one-third) 
of all leucocytes belong to the lymphocyte group — classing all sizes 
together (see Fig. 213, b). 

(c) Eosinophiles. — The nucleus is irregularly contorted and at- 
tracts very little notice, owing to the very brilliant pink color and 
relatively large size of the granules in which it is immersed. The 
outline of the cell is more irregular than that of any other leuco- 
cyte, and its granules often become broken away and scattered in 
the technique of spreading the blood. The eosinophiles make up 
approximately one per cent of the leucocytes of normal blood. 

(d) Mast Cells. — The shape of the nucleus can rarely be made 
out, and the main characteristic of the cell is the presence of large 
dark granules, stained blue or plum color, sometimes almost black, 
and arranged most thickly about the margin of the cell. Mast 
cells are very scanty in normal blood and make up not more than 
one- half of one per cent of the leucocytes. 

Other varieties of leucocytes which appear in the blood only in 
disease will be mentioned later. 

3. Blood Plates. — In the normal blood film, stained as directed 
above, one finds, beside the red corpuscles and the different varie- 
ties of leucocytes, a varying number of bodies, usually about one- 
third the diameter of a red corpuscle, irregularly oval in shape, 
staining dark red or blue and tending to cohere in bunches. Occa- 
sionally larger forms occur, and in these a vague network and some 
hints of a nucleus may be traced. 

The significance of these bodies is unknown and they have at 
present no importance in medicine, although they not infrequently 



THE BLOOD. 



473 



lead to mistakes, because, when lying on top of a red corpuscle, 
they bear a slight resemblance to a malarial parasite. 




III. Counting the White Corpuscles. 

The instrument used all over the world at the present day is the 
pipette of Thoma-Zeiss, in which the blood is diluted either ten or 
twenty times. The diluting solution is one-half of one per cent 
glacial acetic acid in water. This diluting solution often accumu- 
lates spores and be- 
comes cloudy. As soon 
as this happens a fresh 
bottle should be pre- 
pared. After a rather 
deep puncture blood is 
sucked up to the mark 
point .5 on the pipette, 
which is then immersed 
in the diluting solution 
and suction exerted un- 
til the mixture is drawn 
up to the point marked 
11. This gives a dilu- 
tion of one to twenty. 
By drawing blood up 
to the point marked 1, 
instead of to the point 

marked .5, we obtain a dilution of one to ten. After this the ends 
of the pipette can be closed with a rubber band, and the blood, so 
shut in, can be kept or transported without loss or change. 

When we are ready to make the count, the rubber band is re- 
moved and the pipette rolled in the fingers rapidly back and forth 
for about one minute, to mix up the contents of the bulb thoroughly 
and evenly. Next blow out three drops, in order to get rid of the 
pure diluting solution which is in the shank of the pipette. Then 
put upon the circular disc of the counting chamber a drop of the 



FIG. 214. 



Indicating an Order in which the Squares may 
be Counted. 



474 PHYSICAL DIAGNOSIS. 

mixture from the bulb of the pipette. This drop must be of such a 
size that when the cover glass (see Fig. 215 B) is let down upon it 1 
the drop will cover at least nine-tenths of the circular disc and not 
spill into the moat around it. The size of this drop can only be 
learned by practice. After about five minutes the leucocytes will 
have settled upon the ruled space which occupies the centre of the 
floor of the counting chamber, and the count can then be begun, 
using preferably a No. 5 objective of Leitz or a DD of Zeiss. The 
whole ruled space should be counted, and after a little practice this 
takes not more than five minutes. I usually begin my count in the 
left upper corner of the ruled space and proceed in the direction in- 



A C 

Fig. 215.— Thoma-Zeiss Counting Slide. A, Ruled disc : B, cover-glass ; C, moat. 

dicated by the serpentine arrow in Fig. 214. In normal blood one 
finds from thirty to fifty leucocytes in the whole ruled space. The 
number of leucocytes per cubic millimetre is obtained by multiply- 
ing this figure by 200. Thus if the number of leucocytes counted 
is 35, the number in a cubic millimetre of blood is 35 X 200 = 7,000. 
If great accuracy is needed, a second count with a fresh drop should 
be made and the average of the two taken ; but in ordinary clinical 
work this does not seem to me necessary, for the amount of error, 
although considerable, is not such as to affect our diagnostic infer- 
ences. 

IV. Counting the Red Corpuscles. 

Perhaps once in every twenty-five or fifty cases that one sees it 
is well to know the number of red corpuscles. They can then be 
counted with the Thoma-Zeiss pipette which is made for the pur- 
pose, and so arranged that the blood may be diluted one to two hun- 

1 To avoid air bubbles lower the cover glass with aid of a needle as in 
mounting microscopic specimens. This must be done as quickly as possible 
after the drop has been adjusted on the counting disc. 



THE BLOOD. 475 

dred. The technique is exactly that described in the last section, 
except that we need less blood and use a different diluting solution. 
I am accustomed to use a mixture suggested by Gowers, made up 
as follows : 

Sodium sulphate gr. cxii. 

Dilute acetic acid 3 i- 

Water I iv. 

Blood is sucked up to the mark 0.5 and then Gowers' solution 
to the mark 101. After the drop has been adjusted in the counting 
chamber and the corpuscles have settled upon the ruled space, we 
usually count a held of twenty-five small squares at each of the 
four corners of the whole ruled space. The figure so obtained is 
multiplied by 8,000. The result is the number of corpuscles per 
cubic millimetre. 

Interpretation of the Results so Obtained. 

1. Secondary Ancemia. 

The haemoglobin is usually reduced more than the count of red 
corpuscles, giving a low color index. In mild cases the haemoglobin 
may fall as low as forty per cent before the red corpuscles show any 
considerable diminution. In severe cases the red cells fall to 3,000,- 
000, 2,000,000, and occasionally even to 1,000,000 or below it; 
but the haemoglobin usually suffers even more severely. 

The leucocytes may be normal, increased, or diminished, de- 
pending on the cause of the anaemia. Thus in anaemia due to 
chronic suppurative hip-disease the leucocytes are often increased to 
20,000 or 30,000, while in malarial anaemia the leucocytes are often 
subnormal. There are no characteristic changes in the differential 
count, which varies with the underlying disease. 

The changes seen in the stained blood film are briefly : Poikilo- 
cytosis, abnormal staining of the red corpuscles, and the presence 
of nuclei either in normal-sized corpuscles (normoblasts) or in giant 
corpuscles (megaloblasts). The degree of poikilocytosis and abnor- 
mal staining reaction is proportional to the severity of the anaemia. 
In mild cases we find only normoblasts, and those only after a long 



476 PHYSICAL DIAGNOSIS. 

search ; in severe cases we may find niegaloblasts as well, but almost 
invariably these cells are fewer than the normoblasts. 

The commonest causes for secondary or symptomatic anaemia 
are as follows : 

(a) Hemorrhage — gastric, hemorrhoidal, traumatic, puerperal, 
etc. 

(b) Malaria, more rarely sepsis or other infections. 

(c) Malignant disease, 
(e?) Chronic suppurations. 

(e) Chronic glomerulo-nephritis. 

(/) Cirrhosis of the liver. 

(#) Poisons, especially lead. 

(/*,) Chronic dysentery. 

(i) Intestinal parasites. 

It is important to remember that insufficient food or even star- 
vation does not produce anaemia, and so far as we know no form of 
bad hygiene has any notable effect upon the blood. Persons may 
grow very pale under bad hygienic conditions, but their blood is 
usually not affected unless one of the diseased conditions men- 
tioned above is present. 

2. Chlorosis. 

The blood is practically identical with that just described, 
though the color index is sometimes lower, poikilocytosis less 
marked, and nucleated red cells fewer. The pallor of the centres 
of the cells (" achromia") is often very marked. The leucocytes are 
generally normal and the differential count practically so, although 
the percentage of polynuclear cells is often low with a corresponding 
relative increase of lymphocytes. 

3. Pernicious Ancemia. 

The number of red cells is usually below 2,000,000 when the 
case is first seen. The color index is high and the leucocyte count 
subnormal. The stained specimen shows very marked deformities 



THE BLOOD. 477 

and abnormal staining reactions in the red cells, with a tendency to 
the predominance of large forms. Many of the latter contain nu- 
clei ("megaloblasts"), and a smaller number of normal-sized cells 
also contain nuclei ("normoblasts"). 

The polynuclears are relatively diminished, with a correspond- 
ing relative increase in the lymphocytes. 

In the remissions . which form so important a feature of the 
course of pernicious anaemia, the blood is generally transformed 
until it is almost or quite normal. In the subsequent fall it may 
take on all the features of secondary anaemia or chlorosis, and lead 
to unavoidable errors in diagnosis and prognosis. Fortunately cases 
are rarely seen for the first time at this (non-characteristic) stage. 

Interpretation of the Results of the Leucocyte Count and 
Differential Count. 

By combining the facts obtained by the total white count and 
the differential count, we can estimate the number of each variety 
of leucocyte contained in a cubic millimetre of blood. Thus with 
10,000 white corpuscles, 70 per cent of which are poly nuclear (as 
seen in the stained film), we have 7,000 polynuclear cells per cubic 
millimetre, which may be considered the upper normal limit. Any 
number greater than this should be considered as a leucocytosis. In 
a similar way we can say that any number greater than 3,500 is above 
the normal limit for lymphocytes and constitutes a lymphocytosis, 
while eosinophilia is present whenever the number of eosinophiles is 
more than 400 per cubic millimetre. It is much better to use these 
absolute numbers than to rely upon percentages. If we say, for 
example, that 3 per cent of eosinophiles is within normal limits, we 
shall make an error now and then in cases of myelogenous leukae- 
mia, in which, with a total count of 500,000 leucocytes, 3 per cent of 
eosinophiles would amount to a total of 15,000 per cubic millimetre, 
or nearly thirty times the normal number. Errors are also common 
in the opposite direction. For example, in typhoid, with a total 
leucocyte count of 3,000, the lymphocytes may reach 60 per cent 
and yet be well within the normal limits, for 60 per cent of 3,000 is 



478 PHYSICAL DIAGNOSIS. 

only 1,800. In this case the apparent lymphocytosis is due to an 
absolute decrease in polynuclear cells. • 

For the reasons here given it seems to me best to use the follow- 
ing definitions : 

1. Leucocytosis is an increase in the polynuclear cells beyond 
the normal — 7,000. 

2. Lymphocytosis is an increase of lymphocytes beyond the nor- 
mal upper limit — 3,500. 

3. Eosinophil] a is an increase of eosinophils beyond the normal 
upper limit — 500 per cubic millimetre. 

Occurrence of Leucocytosis. 

Leucocytosis, like fever, occurs in a great variety of conditions, 
of which the following are the most important: 

1. In infectious diseases — except typhoid, malaria, uncomplicated 
tuberculosis, measles, smallpox (prior to the pustular stage), 
mumps, and German measles. 

2. In a variety of toxcemic conditions, such as uraemia, hepatic 
toxaemia, diabetic coma, rickets, and poisoning by illuminating gas. 

3. In a minority of cases of malignant disease, especially sar- 
coma. 

4. After violent muscular exertion, including parturition, and 
after cold baths or massage. 

There is in all probability no constant leucocytosis in pregnancy 
or during digestion. 

Leucocytosis is most often of value in the differential diagnosis 
between typhoid fever or malaria on the one hand, and pyogenic 
infections (meningitis, appendicitis, sepsis, pneumonia) on the other. 
A leucocyte-chart is often of value in judging whether a local sup- 
purative process, such as appendicitis, is advancing or receding, or 
whether pus-pocketing has taken place. By a leucocyte-chart is 
meant a series of leucocyte counts at short intervals — twelve, 
twenty-four, or forty-eight hours. Wlien taken in connection with 
the other clinical data, a leucocyte chart is often of the greatest 
value, especially in following the course of any disease ; to a less 



THE BLOOD. 479 

extent in diagnosis. In internal medicine leucocyte counts are 
especially useful in febrile conditions, in the great majority of which 
they assist the diagnosis. 

Certain exceptions to the rules above given must be remem- 
bered : 

1. Quiescent, thickly encapsulated collections of pus, in which 
the bacteria have died or lost their virulence, usually produce no 
leucocytosis. In this group come some of the abscesses of the liver 
or about the kidney, and a few cases of appendicitis. 

2. The most virulent and overwhelming infections are apt not 
to be accompanied by leucocytosis. Thus, for example, the most 
virulent cases of pneumonia, diphtheria, or general peritonitis 
often run their course without leucocytosis. 

Lymphocytosis. 

Only in two diseases does well-marked lymphocytosis occur : 1. 
Lymphatic leukaemia. 2. Whooping-cough and its complications 
(many cases). 

Occasionally lymphocytosis occurs in rickets, hereditary syphi- 
lis, and anything that produces debility in children, Lymphocyto- 
sis is of value chiefly in the differentiation of lymphatic leukaemia 
from other causes of glandular enlargement. 

Eosin op hilia . 

The eosinophils are increased chiefly in : 

1. Bronchial asthma. 

2. Chronic skin diseases. 

3. Diseases due to animal parasites (trichiniasis, uncinariasis, 
filariasis, hydatid disease, Bilharzia disease, trypanosomiasis, and 
with most of the intestinal worms). 

4. Myelogenous leukaemia. 

There seems to be also some vague connection between eosin- 
ophilia and diseases of the female genital tract (except cancer and 
fibroin y oin a of the uterus). 



480 



PHYSICAL DIAGNOSIS. 



Leukjemia. 

Two forms are distinguished, though the distinction is chiefly a 
clinical one : (a) Myelogenous and (h) lymphatic. 



1. Myelogenous Leulccemia. 



when the case is first seen, but often run much higher 



The leucocytes are usually about 250,000 per cubic millimetre 

and some- 
times lower. There is no an- 
aemia in the earliest stages; 
later moderate secondary an- 
aemia develops. 

The differential count shows 
an extraordinary variety of 
types, including many not seen 
in normal blood (see Fig. 216). 
The majority of the leucocytes 
are polynuclears, but many of 
these are atypical in size or in 
the shape of their nucleus. 
From 20 to 40 per cent of the 
leucocytes are myelocytes (or 
mononuclear neutrophiles), the 
" infantile " form of the poly- 
nuclear cell. Lymphocytes are 
absolutely normal or increased, but their percentage is low, on ac- 
count of the greater increase of the other forms. Eosinophiles are 
absolutely much increased, though the percentage is not much above 
normal. Mast cells are more numerous than in any other disease 
(1 to 12 per cent, out of an enormous total increase). Normoblasts 
are usually very numerous; megaloblasts scanty. 

Under the influence of intercurrent infections or after cc-ray 
treatment the blood may return to normal. 




Fig. 216.— Myelogenous Leukaemia, m, Myelo 

cytes; p, pulynuclear ; b, mast cell; n,normo 

blast. 



THE BLOOD. 481 

2. Lymphatic Leukcemia. 

The total increase of leucocytes is usually much less than in the 
other type of leukaemia — 40,000 or 80,000 — or less in average cases. 
The differential count shows an overwhelming proportion of lymph- 
ocytes— 90 to 99.9 per cent as a rule. In the acute forms of the 
disease the large lymphocytes predominate; in chronic cases the 
small forms. 

The blood-film is monotonous in contrast with the wonderful 
variety seen in myelogenous leukaemia (see Fig. 213, h). 

V. The Widal Reaction. 

(a) Technique. Among the numerous agglutinative reactions 
between the serum of a given disease and the micro-organism pro- 
ducing that disease, only one has yet attained wide use in clinical 
medicine, viz., the so-called Widal reaction in typhoid fever. 

There are many ways of performing this reaction, but in my 
opinion the following is the best: 

Measure out in two small test tubes ten drops and fifty drops 
respectively of a highly motile twelve- to twenty-four-hour bouillon 
culture of typhoid bacilli, in which the bacilli have no tendency to 
adhere spontaneously to each other. Carry these tubes and a mi- 
croscope to the bedside, puncture the patient's ear as usual, and 
draw a little blood into a medicine-dropper of the same size as that 
used in measuring out the typhoid culture. Expel one drop of 
blood into each of the tubes containing typhoid culture, and exam- 
ine a drop of each mixture between a slide and cover glass with a 
high-power dry lens. If within fifteen minutes clumping has 
taken place in the 1 : 10 mixture, or if within one hour clumping 
has taken place in the 1 : 50 mixture, the reaction may be consid- 
ered positive. By clumping I mean an agglutination of the bacilli 
into large groups and the complete or nearly complete cessation of 
motility. 

If it is inconvenient to carry the culture and the microscope to 
the bedside, ten or twenty drops of blood may be milked out of the 
ear and collected in a test tube (a three-inch test tube of small cali- 
31 



482 PHYSICAL DIAGNOSIS. 

bre is best). After clotting has taken place, if the edges of the clot 
are separated from the glass with a needle or a wire, a few drops of 
serum will exude, and this serum can be mixed with the bouillon 
culture in the manner already described. 

Less reliable, in my opinion, is the use of blood dried upon glass 
or glazed paper in large drops and subsequently dissolved in the cult- 
ure itself. 

(b) Interpretation. A positive reaction occurs at some period in 
the course of ninety-five per cent of all cases of typhoid fever, but 
the proportion of cases in which the reaction occurs early enough to 
be of diagnostic value varies greatly in different epidemics. In 
most epidemics about two-thirds of the cases show a positive Widal 
reaction by the time the patient is sick enough to consult a physi- 
cian. The reaction maybe absent one day and present on the next, 
and varies greatly in intensity in different cases and at different 
times with the same case. 

VI. Blood Parasites. 

1. The Malarial Parasite (see Plates IV. and V.). 

In films stained as above directed the malarial parasite appears 
blue against the pink background of the corpuscle. A crimson- 
stained dot should appear in some portion of the blue-stained or- 
ganism; the protoplasm of the red corpuscle around it is often 
studded with pink dots. 

The stained specimen is preferable to the fresh blood in the 
search for malarial parasites, for the young, ring-shaped, or " hya- 
line " forms often escape notice altogether in fresh specimens. 

Tertian organisms are distinguished from the sestivo-autumnal 
variety by the following tests : 

(a) Tertian parasites make the corpuscle containing them larger 
than its uninfected neighbors. 

(b) Segmenting forms never occur in the peripheral blood of ses- 
tivo-autumnal fevers. 

(c) " Crescents" (see Plate V.) never occur except in aestivo- 
autumnal fevers. 



THE BLOOD. 



483 



2. The Trypanosoma. 

In Central Africa (and presumably in other tropical countries) 
the blood of many persons is found to contain the organism shown 
in Fig. 217, which has long been known as a parasite of the blood 
of horses and of many of the lower animals. Human trypanosomi- 





FlG. 21' 



-Trypanosoma in Human Blood. (By permission of Dr. J. Everett Dutton and the 
London Lancet.) 



asis — a chronic, debilitating malady — becomes " sleeping sickness " 
when the trypanosoma enters the cerebrospinal canal. 



3. Filar iasis. 

In the blood of many inhabitants of tropical countries there is 
found (with or without symptoms) the parasite shown in Fig. 218. 
The species most often found is present in the peripheral blood only 



484 PHYSICAL DIAGNOSIS. 

at night; hence the blood should be examined after 8 p.m. A fresh 




Fig. 218.— The Filaria Sanguinis Hominis. The bead, curled up, is seen to the right of the cut, 
the tail at the left. Instantaneous photomicrograph. Four hundred diameters magnification. 

drop is spread between slide and cover and examined with a low- 
power lens (So. 5 objective Leitz). 




Fig. 219.— Pratt's Modification of the Brodie-Piussell Coagulometer. i?, Brass ring soldered to 
glass slide ; G, cover glass : a hlood drop on the under side of this, when in place on the brass 
ring, is close to the point of the hollow metal needle which forms the extremity of the infla- 
tion tube, C. 



CABOT-PHYSICAL DIAGNOSIS. 



PLATE IV. 




Fig. 1.— Young Tertian Parasites. (Stained with Wright's modification of 
Irishman's stain.) 




Fig. 2.— Mature Tertian Parasites. (Eosin and methylene blue.) 




Fig. 3.— Segmenting Tertian Parasites. (Eosin and methylene blue.) 



CABOT-PHYSICAL DIAGNOSIS. 



PLATE V. 




Fig. 1.— Two Young ^stivo-autumnal Parasites. (Wright's modiflcation of 
Leishman's stain.) 




Fig. 2.— ^stivo-autumnal Parasites. Ring body at the left ; crescent at the right. 
Stained like Fig. 1. 




Fig. 3.— Ovoid in ^stivo- 
autumnal Malaria. 



Fig. 4.— Crescent in JEstivo-autumnal Malaria. 



THE BLOOD. 485 



VII Estimation of Coagulation Time. 

The Brodie-Russell instrument, as modified, by Pratt 1 (see Fig. 
219), is, in my opinion, by far the best. To use the instrument, 
we put a drop of water on the slide inside the metal ring (H). 
Smear this ring with vaseline. Put a drop of blood on the under 
side of the cover glass and press the latter down into the vaseline, 
so that the blood drop comes in the middle of the metal ring. Then 
watch it with a low power of the microscope; at intervals of one 
minute a current of air is brought into contact with the drop by 
means of a rubber tube and bulb, C. As soon as coagulation has 
taken place, tbe impact of this current of air ceases to make the 
corpuscles fly about. 

Normally, coagulation occurs under these conditions in from 
three to eight minutes; anything outside these limits is to be con- 
sidered pathological. 

The estimation of coagulation time seems to be of some value to 
surgeons in relation to the question of operation in cases of hem- 
orrhagic tendency (purpura, jaundice, and various liver diseases). 

1 Pratt: Journal of Medical Research, November, 1903. The instrument 
costs 75 cents. 



CHAPTER XXIV. 

THE JOINTS. 
Examinations of the Joints. 

A. Methods and Data. 

I. By inspection and palpation we detect : 

1. Pain, tenderness, and heat in, near, or at a distance from the 
joint. 

2. Enlargement: 

(a) Hard, probably bony. 

(b) Boggy, probably infiltration or thickening of capsule and 
periarticular structures. 

(c) Fluctuating, probably fluid in the joint. 

3. Irregularities in contour : 

(a) Osteophytes or "lipping" (attached to the bone). 

(b) Gouty tophi (not attached to the bone). 

(c) Constriction-line opposite the articulation. 

(d) Protrusion of joint-pockets in large effusions, filling out of 
natural depressions. 

4. Limitation of motion : 

(a) Due to pain and effusion. 

(b) Due to muscular spasm. 

(c) Due to thickening or adhesions in the capsular and periartic- 
ular structures. 

(d) Due to obstruction by bony outgrowths or gouty tophi. 

(e) Due to ankylosis. 

5. Excess of motion (subluxation). 



THE JOINTS. 487 

6. Crepitus and creaking. 

7. Free bodies in the joint. 

8. Trophic lesions over or near a joint (cold, sweaty, mottled, 
cyanosed, white, or glossy skin, muscular atrophy). 

9. Sinus formation, the sinus leading to necrosed bone, to gouty 
tophi, or abscess in or near the joint. 

10. Distortion and malposition, due to contractures in the mus- 
cles near the joint, to necrosis, to exudation, or to subluxation. 

"11. Telescoping of the joint with shortening (limb, toe, finger, 
or trunk). 

11. By radioscopy we investigate : 

1. Bony outgrowths, their shape, extent, and position. 

2. Necroses and atrophies of bone, their extent and position. 

3. The structure of the bones in and near the joints. 

4. The presence of lesions in the articular cartilages. 

5. Free joint bodies, their presence and position. 

III. Indirectly we may gain valuable information about the 
joints by noting: 

1. General constitutional symptoms, their presence or absence. 
These include fever, chills, leucocytosis, glandular enlargement, 
albuminuria, and emaciation. 

2. Tuberculin reaction, its presence or absence. 

3. Disease of other organs, their presence or absence, i.e., syph- 
ilis, tuberculosis, tabes, and other chronic spinal-cord lesions, en- 
docarditis, haemophilia, various acute infections (gonorrhoea, influ- 
enza, scarlatina, septicaemia), and skin lesions (psoriasis, purpura, 
hives). 

4. The course of the disease and the results of treatment. 

B. Technique of Joint Examination. 

(a) Enlargement is generally unmistakable, but when there is 
much muscular atrophy between the joints the latter may seem en- 
larged by contrast, when in fact they are not. 

(IS) Fluctuation is obtained in most joints, as in any part of the 
body, by pressing a finger on each of two slightly separated spots 



488 PHYSICAL DIAGNOSIS. 

in the suspected area, and endeavoring to transmit through the in- 
tervening space an impulse from one finger to the other. Fat or 
muscle will also transmit an impulse, but less perfectly than fluid. 
In the knee we test for " floating of the patella " over an effusion 
by surrounding the joint with the hands, which are pressed slightly 
toward each other to limit the escape of fluid in either direction, 
and then suddenly making quick pressure on the patella with one 
finger. If we feel or hear the patella knock against the bone below 
and rebound as we release the pressure, fluid in abnormal quantity 
is present. 

(c) Irregularities of contour are easily recognized, provided the 
normal contour is familiar. 

(d) Bony outgrowths may be obvious (as in Heberden's nodes), 
but if within the joint they may be recognized only by the sudden 
arrest of an otherwise free joint motion at a certain point. In many 
cases radioscopy is necessary. 

(e) Gouty tophi are identified positively by transferring a minute 
piece to a glass slide, teasing it in a drop of water, covering with 
a cover glass, and examining with a high-power dry lens and a 
partly closed diaphragm. The sodium biurate crystals are charac- 
teristic. 

Fluid or semi-fluid exudates in joints may fill up and smooth out 
the natural depressions around the joint, or, if the exudate is large, 
may bulge the joint pockets; in the knee-joint four eminences may 
take the place of the natural depressions, two above and two below 
the patella. 

(/) Limitations of motion due to muscular spasm are seen with 
especial frequency in tuberculous joint disease, but may occur in 
almost any form of joint trouble, particularly in the larger joints. 

(1) Hip-joint, two forms of spasm are important: (1) That 
which is due to irritation of the psoas alone (psoas spasm,); (2) that 
in which all the muscles moving the joint are more or less con- 
tracted. 

In pure p/soas spasm the thigh is usually somewhat flexed on the 
trunk, though this ma} 7 be concealed by forward bending of the lat- 
ter. Very slight degrees of psoas spasm may be appreciable only 



THE JOINTS. 



489 



when, with the patient lying on his face, we attempt hyperexten- 
sion (see Fig. 220). 

The other motions of the hip — rotation, adduction, abduction, 
and flexion — are not impeded. 

General sjyasm of the hip muscles is tested with the patient on 
the back upon a table or bed (a child may be tested on its mother's 




Fig. 220.— Testing for Psoas Spasm. (Bradford and Lovettf.) 



lap) and the leg flexed to a right angle, both at the knee and at the 
hip. Using the sound leg as a standard of comparison, we may 
then draw the knee away from the middle line (abduction), toward 
and past the middle line (adduction), and toward the patient's 
chest (flexion). Eotation is tested by holding the knee still and 
moving the foot away from the median line of the body or toward 
and across it 

(2) Spinal column. Muscular spasm of the muscles guarding 
motion in the vertebral joints can be tested by watching the body 
attitude (a stiff, "military" carriage in most cases), and by efforts 
to bend the spine forward, backward, and to the sides. 

In most cases we can make out limitation of these motions by 
asking the patient to stand with knees and hips stiff and then bend 
his trunk (of course, naked) as far as he can in each of the four 
directions. If we are familiar with the average range of motility 



490 PHYSICAL DIAGNOSIS. 

in each direction and at the different ages, this test is usually easy 
and rapid. Backward bending is the least satisfactory, and in 
doubtful cases the patient should be on his face, while the physi- 
cian, standing above hirn, lifts the whole body by the feet (see Fig. 
221). 

(3) In the joints of the shoulder, knee, elbow, wrist, ankle, 
toes, and fingers, there is usually no difficulty in testing for muscu- 
lar spasm, and no special directions are needed. 

To distinguish muscular spasm from bony outgrowth as a cause of 
limited joint motion, we should notice that bony outgrowths (e.g., 




Fig. 221.— Rigidity of Spine in Pott's Disease. 

in the hip) allow perfectly free motion up to a certain point ; then 
motion is arrested suddenly, completely, and without great pain. 
Muscular spasm, on the contrary, checks motion a little from the 
outset, the resistance and pain gradually increasing until our efforts 
are arrested at some point, vaguely determined by our strength and 
hard-heartedness and by the patient's ability to bear the pain. 

Motions limited by capsular thickening and adhesions are not, 
as a rule, so painful after the first limbering-up process is over. 
There is no sudden arrest after a space of free mobility, but motion 



THE JOINTS. 491 

is limited from the first and usually in all directions, though the 
muscles around the joint are not rigid. The possibility of more or 
less limbering-out after active exercise (or passive motion) distin- 
guishes this type of limitation. 

In true ankylosis, there is no motility whatever. 

(y) Excessive motion in a joint is recognized simply by contrast 
with the limits furnished us by our knowledge of anatomy and of 
the physiology of joint motion at different ages. When the bone 
and cartilage appear normal or are not grossly injured, we call the 
excessive motility of the joint a subluxation, but excessive motility 
may also be due (as in Charcot's joint) to destruction of bone and 
other essentials of the joint. 

(A) To detect crepitus and creaking we simply rest one hand on 
the suspected joint, and with the other put it through its normal 
motions, while the patient remains passive. 

(i) Most free joint bodies are not palpable externally, and are rec- 
ognized only by their symptoms, by the #-ray, and by operation. 

(j) Shortening of a limb as evidence of joint lesions is tested by 
careful measurements. The vast majority of such measurements 
are made with reference to the hip-joint. The tip of each anterior 
superior iliac spine is marked with a skin-pencil, and likewise the 
tip of each inner malleolus. Then, with the patient lying at fall 
length on a flat table, the distance from anterior superior spine to 
inner malleolus is measured with a tape on each side. 

The method of obtaining the other data tabulated on page 486 
needs no explanation, except the radioscopic technique — a subject 
which I am not competent to discuss. 



C. Joint Diseases. 

I shall use the classification proposed by Goldthwaite and divide 
joint diseases as follows : 

1. Infectious arthritis : (a) Tuberculosis. (&) Other infections. 

2. Atrophic arthritis : (a) Primary, (b) Secondary to organic 
nerve lesions (Charcot's joint). 



492 PHYSICAL DIAGNOSIS. 

3. Hypertrophic arthritis. 

4. Gouty arthritis. 

5. Hsemophilic arthritis. 

Under infectious arthritis are included all varieties of articular 
" rheumatism " and the joint troubles symptomatic of gonorrhoea, of 
streptococcus infections (including scarlet fever), influenza, syphi- 
lis, typhoid, and other fevers. As tuberculosis is an infection we 
must include it in this group, although the disease begins usually 
as an osteitis and involves the joint secondarily by extension. 

I. Tuberculous Arthritis. — The characteristics of joint tubercu- 
losis are : 

(a) Slow progress, with gradual enlargement and disabling of the 
joint. 

(J>) Muscular spasm, especially in disease of the hip or vertebrae. 

(c) Evidences of low-grade inflammation (moderate heat, swell- 
ing, pain, and tenderness). 

(d) Abscess and sinus formation. 

(e) Malpositions {e.g., shortening of one leg in hip-joint disease, 
angular backward projection in spinal disease, subluxations in the 
knee-joint). 

(/) Bone necrosis, as shown by sc-ray. 

The order of frequency in the different joints is as follows: 
spine, hip, knee, wrist, shoulder (tuberculous dactylitis is described 
on page 50). 

In the deep-seated hip-joint, diagnosis has to depend largely on 
shortening and on the presence of limitation of all the hip motions 
by muscular spasm (see above, page 489), unless the disease is of 
long standing and manifests itself by abscesses burrowing to the 
surface. Usually these abscesses point in the upper anterior thigh, 
but they may open behind the great trochanter, below the gluteus 
maximus, or at any point in the vicinity of the hip. 

Besides muscular spasm, shortening, and abscess formation, we 
get some aid from the general and vague joint symptoms present in 
this as in many other joint lesions. Such are enlargement (felt as 
thickening about the great trochanter), muscular atrophy, pain, ten- 
derness, and crepitus. 



THE JOINTS. 493 

In spinal tuberculosis (Potfs disease) the distortion of the bones 
with formation of a knuckle in the back is often obvious and prac- 
tically diagnostic. In other cases we depend on muscular spasm or 
abscess formation. The muscular spasm gives a stiff back and often 
psoas contraction (see below). The abscess is peculiar, in that it 
usually works along in the sheath of the psoas and points in the 
groin below Poupart's ligament (see Fig. 202); less often it appears 
in the back or in the gluteal region, and rarely it may invade almost 
any part of the body (lung, gullet, gut, peritoneum, rectum, hip- 
joint, etc.). 

Psoas spasm, which is common both in hip and spinal tubercu- 
losis, is by no means peculiar to these diseases, and it is worth re- 
membering that it may be due to various other lesions, such as : 

(a) Hypertrophic arthritis of the spine. 

(&) Appendix abscess. 

(c) Perinephritic abscess. 

In the peripheral joints (shoulder, elbow, wrist, finger, knee, 
ankle) the diagnosis of tuberculosis rests on the chronic enlarge- 
ment and disability, with abscess and sinus formation. 

Hysterical or acute traumatic lesions (with or without neurosis) 
may present symptoms and signs identical with those of tubercu- 
losis. Decision is aided most by : (a) The lapse of time and the ef- 
fects of treatment, (b) arRay examination, (c) The predominance 
in functional and traumatic cases of pain and tenderness rather than 
muscular spasm or malposition. 

II. Acute Infectious Arthritis. — All varieties are distinguished 
from the other types of arthritis by : (a) The absence of any marked 
bone lesions 1 inmost cases. (#) The tendency to recovery in the great 
majority of cases. 

The milder forms, whose cause is unknown, we have hitherto 
designated as "rheumatism." The others are distinguished as 
gonorrhoea^ pneumococcic, syphilitic, influenzal, dysenteric, etc., 
according to the organism producing them. 

Between this group and those known as "rheumatism," there is 

1 Exceptionally, virulent infections (especially those due to pneumococci or 
streptococci) may destroy cartilage and bone and end in true bony ankylosis. 



494 



PHYSICAL DIAGNOSIS. 




Fig. 222.— .r-Ray of Hand in Atrophic Arthritis. Note that the rays pass through the articular 
ends of the bone without resistance (hence no shadow there). (Carson.) 



THE JOINTS. 



495 



no clear pathologic distinction. Mild infection with pyogenic cocci 
may leave a sound joint, though the general tendency is to crippling 
through fibrous adhesions. On the other hand, arthritis of "rheu- 
matic" (i.e., of unknown) origin may end in suppuration, crippling 
the joint with adhesions, though in most cases it leaves a sound 
joint. 

All the members of the infectious group of joint lesions present 
the local signs of inflammation and the constitutional signs of infec- 



r 


Hi . 


Hpp^ j^ 





a b 

Fig. 223.— a, Charcot's Joint with Loose Bodies ; b, Pulmonary Osteo-arthropathy. 



tion. All may be complicated by endocarditis, but in those of un- 
known origin '(" rheumatic") this complication is especially com- 
mon. There is no bony hypertrophy, bone destruction, 1 sinus 
formation, or marked irregularities of contour. A general enlarge- 
ment (more or less spindle shaped, owing to periarticular thick- 
ening and muscular atrophy) is the rule. The joint motions are 

1 See note on page 493. 



496 PHYSICAL DIAGNOSIS. 

limited chiefly by pain and effusion; muscular spasm is not prom- 
inent. 

One or many large or small joints may be affected in any of the 
varieties of infectious arthritis, though the gonorrhoeal virus is apt 




Fig. 224.— Atrophic Arthritis. Early stage. 

to lodge in few joints (oftenest the knee or ankle) and the "rheu- 
matic " virus in many joints, while the typhoid poison has a predi- 
lection for the spine. 

III. Atrophic Arthritis. — Two types must be recognized: (a) A 
monarticular form, secondary usually to tabes or syringomyelia 
("Charcot's joint," "neuropathic joint"), and other diseases of the 
spinal cord, (b) A polyarticular primary form (" rheumatoid ar- 
thritis"). 

In both, the distinguishing characteristic is atrophy and destruc- 
tion of cartilage, bone, and joint membranes — a process which in 
the early stages can be identified only by the cc-ray (see Fig. 222). 



THE JOINTS. 



497 



Later the disintegration of the joint is usually evident, and is fol- 
lowed by distortions, contractures, and ankylosis. 

(a) The monarticular form is generally easy to recognize on ac- 
count of its rapid, painless course, with semifluctuant swelling, 
secondary to a well-marked cord lesion, such as locomotor ataxia. 
A large joint is almost always affected, oftenest the knee, less often 
the hip, shoulder, or elbow. 
The joint shows abnormal 
mobility and the bones can 
often be felt to grate (see Fig. 
223). 

(&) The primary polyartic- 
ular form usually begins in 
the fingers, and is very apt to 
occur symmetrically, i.e., in 
corresponding joints of both 
hands at the same time (see 
Fig. 224) . The joints are en- 
larged, boggy, spindle shaped 
(owing to the rapid atrophy 
of the interossei), often abnor- 
mally white, apparently fluct- 
uant, and show trophic skin 
lesions (glossy skin, sweat- 
ing, mottling) (see Fig. 225). 
The terminal finger- joints are 
rarely swollen. Late in the 
course of the disease a ring of constriction often marks the line of 
articulation (see Fig. 226). Pain is not severe until motion is at- 
tempted or unless the joint is jarred and stirred up by some trau- 
matism. 

The changes progress slowly and attack new and larger joints, 
moving centrally from the periphery. At any stage the process 
may become arrested, but usually not until ankylosis or contractures 
have occurred in one or many joints. Some of the "ossified men " 
of dime museums are in the ankylosed stage of this terrible malady. 
32 




Fig. 225.— Atrophic Arthritis. (Goldthwaite.) 



498 PHYSICAL DIAGNOSIS. 

Flexion of fingers with hyperextension of the terminal joints and 
deflection to the ulnar side are common deformities. 

IV. Hypertrophic Arthritis. — Bony enlargement and osteophytic 
spurs are the distinguishing feature. The new bone is oftenest de- 
posited round the edges of the articular cartilage, forming an irreg- 
ular fungoid ring ("ring bone" in horses) or "lip" near the joint. 




Fig. 228.— Atrophic Arthritis. Late stage with constriction ring at the joint line. (Goldthwaite.) 

The attachments of the ligaments {e.g., the anterior lateral liga- 
ment of the spine or the cotyloid ligament in the hip-joint) furnish 
another favorite site for the bony deposits. 

(a) In the terminal finger-joints (" Heberderi' 's ?iodes ,, ~) the 
process may remain for years without extending to any other 
articulation and without producing any discomfort (Figs. 50 and 
227). 

(5) The disease may be limited to the hip-joint ("morbus coxae 
senilis ") or to any other single joint, producing purely mechanical 
disturbances by limitation of motion. There is no considerable 
muscular spasm, and motion is quite free up to a certain point, at 



THE JOINTS. 



499 



which it is suddenly " locked " by the interference of the bony out- 
growths. The situation, size, and shape of these outgrowths can be 
shown, as a rule, by the x-ray alone. Pain and swelling are 
slight or absent, unless traumatism (internal or external) stirs 




Fig. 227.— Hypertrophic Arthritis with Heberdeii's Nodes. 



up the joint and produces a synovitis. The chief complaint is of 
stiffness. 

(c) Several joints may be affected, and there may result much 
pain because nerves pass through or over the new-formed bone and 
are compressed by it. This form is most often seen in the spine 
("spondylitis deformans," "osteoarthritis "), where a portion of the 
front and side of the vertebral column is " plastered over " with 
new-formed bone (see Fig. 228), which later invades the interverte- 



500 



PHYSICAL DIAGNOSIS. 



bral cartilage and produces ankylosis (see Fig. 229) , either a straight 
" ramrod " spine or a forward curved spine. 



new- 

foraied v — 
bone \ 




Fig. 228.— Hypertrophic Arthritis of Spine. (Goldthwaite.) 



THE JOINTS. 501 

In the early stages the disease is recognized by : 

(a) Nerve pain, running round the body or down the legs, 1 as 
the intercostal and spinal nerves are pressed on. 

(b) Limitation of Motion. The process is usually unilateral, 
wholly or predominantly; hence the patient can usually bend much 




Fig. 229.— Hypertrophic Arthritis (Spine) of Spine with Ankylosis. (Goldthwaite.) 

better to one side (see Figs. 230 and 231) than to the other. Mo- 
tion is also more or less limited in other directions, but forward 
bending is fairly well performed as a rule, in sharp contrast with 
" lumbago," which renders forward bending and the subsequent re- 
covery almost impossible. 

(c) Coughing or sneezing often gives great pain, probably because 
the costo- vertebral joints are involved in the new growth; if anky- 
losis of these joints occurs later, the respiratory movements of the 
chest are interfered with. 

V. Gouty Arthritis. — The deposits of urate of sodium in the 
soft structures around the joint are, like those in the ear (see 

^any neuralgias and sciaticas are due to this disease. 



502 



PHYSICAL DIAGNOSIS. 




Fig. 230.— Showing Normal Flexibility of Spine. (Goldthwaite.) 






litei 





Fig. 231.— Hypertrophic Arthritis of Spine. Motion to left limited. (Goldthwaite.) 



THE JOINTS. 



503 



Fig. 232), close beneath the skin or perforate it, and hence are 
recognizable (as above explained) by microscopic examination. 

They somewhat resemble the nodes of hypertrophic arthritis, 
but are not attached to the bone and can be moved about in the soft 
structures over it. :r-Ray 
examination shows that 
there is often considerable 
destruction of bone in the 
vicinity of the tophi (see 
Figs. 233 and 234). 

VI. Hcemophilic Ar- 





Fig. 232.— Gouty Tophus in the 
Ear. 



Fig. 233.— Gouty Arthritis. (Goldthwaite.) 



thritis. — A chronic stiffening and enlargement of the joint, re- 
sembling in many respects the joint of hypertrophic arthritis, 
but often accompanied by the formation of fibrous adhesions, en- 
sues in some cases of haemophilia, presumably as a result of fre- 
quent hemorrhages and serous oozings in the joint. The diagnosis 
depends on the evidence of haemophilia, the youth of the patient, 
and the absence of infection as a causative factor. 



504 



PHYSICAL DIAGNOSIS. 



Relative Frequency of the Various Joint Lesions. 1 — The 
following table was prepared by Dr. Vickery 2 from the records of 




Fig. 234.— .r-Ray of Hand in Gouty Arthritis. (Goldthwaite.) 



the Massachusetts General Hospital (1893-1903) : 



Infectious arthritis^} 
I 



f Acute rheumatic arthritis 591 

Subacute rheumatic arthritis 193 



Gonorrhoeal arthritis 86 

[Typhoid arthritis (spine) 3 

Hypertrophic and atrophic arthritis 

Gout 



^873 



•43 



1 Chronic villous arthritis ("dry joint ") is a purely local process and there- 
fore receives no further mention here. 

8 Boston Med. and Surg. Jour., November 17th, 1904. 



CHAPTER XXV. 

THE NEKVOUS SYSTEM. 
Examination of the Nervous System. 

The outlines of neurological diagnosis depend on knowledge of: 

I. Disturbances of motion. 

II. Disturbances of sensation. 

III. Disturbances of reflexes (including sphincteric and sexual 
reflexes). 

IV. Disturbances of electrical excitability. 

V. Disturbances of speech and handwriting. 

VI. Disturbances of nutrition ("trophic"). 

VII. Psychic disorders. 

I shall attempt no topical diagnosis of nerve lesions, no diag- 
nosis, that is, depending on memorizing the brain areas, cord lev- 
els, or skin-and-muscle areas corresponding to particular nerve 
lesions. The general practitioner for whom this book is intended 
will not attempt to carry such points in his head, but will refer to 
specialists or special text-books when the case confronts him. The 
general methods most often employed are all that I attempt to de- 
scribe. 

I. Disorders of Motion. 

1. Gaits. 

2. Paralyses. 

3. Spasms and tremors. 

4. Ataxia. 

1. Gaits. — The most important gaits are: 
(a) The spastic. 
(&) The ataxic. 



506 PHYSICAL DIAGNOSIS. 






(c) The gait of. paralysis agitans. 

(d) The toe-drop gait. 

(e) The gait of simple wealmess. 

With the spastic gait there is rigidity of the legs, making it 
difficult to lift the feet ; hence the patient scuffs along, usually with 
bent knees and as if his feet were fastened to the ground. 1 

The ataxic gait is difficult to describe. The patient is not inns- 
cularly weak, but does not know where his feet are or where the 
ground is; hence he flounders and throws his feet about irregularly. ' 

The gait of paralysis agitans is an exaggeration of the old man's 
gait, such as we often see on the stage. The whole body is bent 
forward and rigid (see Fig. 235), and, if progress is accelerated by 
a push given from behind, the patient may be unable to stop himself. 

In the toe-drop gait the foot is raised high and slapped down 
upon the ground with a flail-like motion. 

2. Paralysis or Paresis. — No detailed account can be given here 
of the method of testing individual muscles for loss or impairment 
of power. In general, a knowledge of the origins and attachments 
of muscles enables ns to work out for ourselves a series of tests 
that will bring any desired group into contraction. It is convenient 
to class paralyses according to their origin as follows : 

(a) Brain paralysis : usually hemiplegia (arm and leg on same 
side, with or without the face). 

(l>) Cord paralysis : usually paraplegia, (both legs, rarely both 
arms) or monoplegia (one extremity). 

(c) Cranial nerve paralysis : usually one or more eye muscles. 

(el) Peripheral nerve paralysis : special muscle groups, oftenest 
the extensors of the wrist or foot, the shoulder muscles, and those 
supplied by the facial nerve. 

(e) Hysterical paralysis : no strict anatomical distribution, of- 
tenest monoplegia (one extremity). 

Peripheral nerve paralyses are especially apt to be accompanied 
by sensory symptoms, electrical changes, and wasting. Brain paral- 

1 The cross-legged gait is a spastic gait in which the adductors of the thighs 
are so contracted that the feet tend to be crossed. This gait is oftenest seen 
in the congenital spastic paralyses. 



THE NERVOUS SYSTEM. 



507 






yses have relatively few sensory symptoms (sometimes paresthe- 
sia, see below, page 510) and relatively slight wasting. Mental 
changes, coma, or convulsions often precede or follow them. Cord 




Fig. 235.— Attitude Characteristic of Paralysis Agitans. (Curschmann.) 



paralyses may or may not show these associations, but are often 
accompanied by disorders of the bladder and rectum. 

3. Spasm, Tremor, and Fibrillary Twitching. — (a) Spasm means 
involuntary muscular contraction. The familiar "cramp n is a good 
example of the type of spasm known as tonic S2^asm. In contrast 
with this is the clonic sjiasm, in which flexors and extensors con- 
tract alternately to produce a motion like that of our forearm when 



508 PHYSICAL DIAGNOSIS. 

we shake up a fluid in a test tube, or like the ankle clonus (see 
below) . 

Spasms may be general or local, i.e., involve few or many mus- 
cles. In strychnine poisoning the whole body may be thrown into 
rigidity or general tonic spasm. At the beginning of an epileptic 
seizure the body stiffens out (tonic spasm), then becomes "con- 
vulsed " {general clonic spasm). Local tonic spasm is exemplified in 
the ordinary "cramp." The spastic gait, above described, is an- 
other common example of tonic spasm limited mainly to one group 
of muscles. The contractures which so often affect the sound mus- 
cles in a partially paralyzed limb (see above, page 506) are also ex- 
amples of local tonic spasms. 

Athetosis, a special variety of local tonic spasm, has been de- 
scribed on page 45. 

Local clonic spasm is not common. It may be due to irritation 
of a small portion of the cerebral cortex by various lesions (" Jack- 
sonian epilepsy "), and sometimes precedes or alternates with the 
general spasms of ordinary epilepsy. It also occurs in hysteria. 

Artificially a momentary or prolonged clonic spasm of the foot 
muscles is often produced in testing for the ankle clonus (see below, 
page 513). 

(b) Tremor may be defined as a clonic spasm of short excursion. 
Its causes and varieties have already been discussed (see page 43). 

(c) Fibrillary twitchings means the brief repeated contraction of 
small bundles of muscle fibres. It is seen in patients who are cold 
or nervous, in many debilitated and neurasthenic conditions, and 
often in muscles affected by progressive muscular atrophy. 

(d) Choreic and choreiform movements have already been de- 
scribed (page 44). 

4. Ataxia. — Inco-ordination of the various muscles which nor- 
mally act together to produce a well-directed movement is called 
ataxia. All young infants exhibit ataxia in their more or less un- 
successful grasping movements. Alcoholic intoxication often pro- 
duces typical ataxia, and it is also exemplified in the gait of tabes 
dorsalis. There is no lack of muscular contraction — often too much 
— but it is disorderly and ill-directed. 



THE NERVOUS SYSTEM. 509 

Deficiency in the power to balance in standing or walking is per- 
haps the commonest type of ataxia, and may be due not only to the 
causes just mentioned, but also to cerebellar disease and ear dis- 
ease. In these types there is often a tendency to stagger in one 
particular direction, e.g., to the right, and the ataxia is associated 
with vertigo and with other evidences of brain tumor or of ear dis- 
ease. 

In tabes dorsalis and other diseases we test the power to bal- 
ance by asking the patient to bring his feet together (toe to toe and 
heel to heel) and to close his eyes. If he is unable to preserve his 
balance his failure is known as "Romberg's sign." 

11. Disorders of Sensation. 

The following are the most important types : 

1. Anaesthesia (or insensibility to pain, to touch, to heat and 
cold, and to muscle sensation). 

2. Hijpercesthesia (or over sensitiveness') . 

3. Paresthesia (abnormal, false, or disordered sensation). 

4. Pain. 

5. Disorders of special sense. 

These disturbances may all be seen in different stages or types 
of lesions of the spinal cord or peripheral nerves. They are less 
common in brain lesions. 

1. Tests of anaesthesia are time-consuming and difficult, because 
we depend for our data on the patient's intelligent answer to the 
question, "Do you feel that?" As a rule, we cover the patient's 
eyes and then touch the suspected parts — first lightly, then more 
strongly — questioning him to see if he feels the touch, can judge 
the nature of the touching object (finger, pencil, pin), and tell 
where he is touched. A pin-prick is oftenest used to test pain 
sense, and test tubes filled, one with hot, one with cold water, are 
convenient for trying the temperature sense. Finally, we try 
whether the patient can recognize familiar objects placed in his 
hand and can tell the position in which you may put his arms or 
legs. Failure to make these discriminations is known as astereog- 



510 PHYSICAL DIAGNOSIS. 

nosis, and occurs oftenest iu brain lesions affecting the temporal 
lobes. 

Dissociation of sensation — the preservation, for example, of 
sensations of touch with loss of those of pain and temperature — 
occurs oftenest in syringomyelia. 

Delayed sensation and mistakes regarding the point touched in 
testing are commonest in tabes dorsalis, which disease presents a 
great variety of sensory disorders not here catalogued. 

The distribution of anaesthesia depends, like the distribution of 
paralysis, on the lesion. Hemianesthesia is seen oftenest in hyste- 
ria and organic 'brain lesions. Cord lesions, such as transverse mye- 
litis or compression of the cord, usually produce anaesthesia in the 
area supplied by the spinal nerves below the lesion. Peripheral 
nerve lesions may produce anaesthesia of the skin areas supplied by 
the nerve in question. 

Areas of hysterical anaesthesia (with hyperaesthesia and paraes- 
thesia) usually do not correspond to the distribution of any set of 
nerves or centres, and are distinguished by this fact. 

2. Hyperesthesia is most often recognized as hyperaesthesia for 
pain (tenderness) or in the special senses (sensitiveness to light or 
noise). It is commonest in peripheral nerve lesions and in hyste- 
ria. The tests are the same as those for anaesthesia. 

3. Paresthesia is commonest in the form of the familiar prick- 
ling and tingling felt when one's arm or leg has "gone to sleep." 
Sensations as of crawling insects are not uncommon ; the " hot feet " 
of many elderly persons (with arteriosclerosis) and the "burning 
hands " of many washerwomen are other familiar examples. 

Local paresthesia is not uncommon in lesions of the cerebral 
cortex, and constitutes the preliminary " aura " with which many 
attacks of epilepsy are ushered in. Well-developed tabes dorsalis 
shows many curious or distressing varieties of parsesthesia, as do 
many other varieties of peripheral neuritis. 

III. Reflexes. 

We may distinguish : 
1. Pupil reflexes. 



THE NERVOUS SYSTEM. 511 

2. Deep reflexes (tendon reflexes). 

3. Superficial reflexes (skin reflexes). 

4. Sphincter ic reflexes. 

5. Sexual reflexes. 

1. Pupil reflexes have been described on page 15. 

2. Tendon Reflexes. — Among the most important of these is the 
knee-jerk (quadriceps tendon); less important are the ankle-jerk 
(Achilles tendon) and ankle clonus, the wrist, elbow, and jaw re- 
flexes. 

To test the knee-jerk many methods are used; the following 
seems to me the best : The patient sits with his knees flexed at a 
blunt angle. The physician lays his left hand on the front of the 
thigh and strikes the tendon of the quadriceps, just below the pa- 
tella, with the finger tips of the right hand or with a rubber ham- 
mer. The left hand feels the sudden contraction of the quadriceps 
whether the foot jerks or not. If no contraction is obtained we 
should try what is known as u reenf or cement of the knee-jerk." 
The essence of this is concentration of the patient's attention on 
a voluntary muscular contraction in another part of the body. We 
may accomplish this by asking the patient to hook the fingers of 
his hands together, and at a given signal to give a quick pull upon 
them and then let go. The physician gives the signal (often 
the word " now ") and strikes the patella tendon at the same mo- 
ment. 

The knee-jerk is often wanting or feeble in young infants. It 
varies a great deal in persons of different temperament; in high- 
strung or oversensitive persons and in the Jewish race very lively 
knee-jerks are often seen without disease. 

Absence of knee-jerk is oftenest found in : 

{a) Peripheral neuritis (alcoholic, diphtheritic, lead, etc.). 

(b) Tabes dorsalis. 

(c) Anterior poliomyelitis (on the paralyzed side). 

(d) In the deepest coma from any cause. 

(e) In complete severing of the spinal cord. 
Given a case without knee-jerks : 



512 PHYSICAL DIAGNOSIS. 

Neuritis is suggested by the history and etiology, by the pres- 
ence of marked sensory symptoms (pain, tenderness), and the ab- 
sence of symptoms pointing to the brain or cord. 

In tabes the Argyll-Robertson pupil, the disturbance of the 
sphincters and sexual power, the " lightning pains " here and there, 
the presence of Romberg's symptom (see page 509), and later the 
ataxic gait are important confirmatory signs. 

Anterior poliomyelitis presents a flaccid paralysis, usually of one 
extremity, coming on suddenly in a young child and wholly with- 
out sensory symptoms. 

Comatose patients, if the coma is due to cerebral hemorrhage 
and is not of the profoundest type, often show increased knee-jerks 
on the paralyzed side; but in very profound unconsciousness all 
reflexes are lost. 

Partial destruction of the cord often increases the reflexes, but 
total division usually abolishes them. 

Increased knee-jerk is found in : 

(a) Cerebral paralyses (infantile, apoplectic, dementia paralytica, 
etc.). 

(b) Spastic paraplegia and the amyotrophic forms of lateral 
sclerosis. 

(c) Many cord lesions, localized above the lumbar enlargement 
(transverse or pressure myelitis). 

(d) In the earliest stages of peripheral neuritis (some later). 

(e) Multiple sclerosis. 

(/) Some forms of chronic arthritis. 

Differential diagnosis of cases with increased knee-jerks : 
Cerebral paralyses usually manifest their place of origin by the 

presence of psychic symptoms (coma, idiocy, dementia) and by 

convulsions. The paralysis is usually hemiplegic and involves no 

wasting beyond the atrophy of disuse. 

Spastic paraplegia is readily recognized by the gait (see page 

506) and the absence of marked sensory or sphincteric symptoms. 

Its pathology is not known. If marked wasting of the muscles 

occurs it is termed "amyotrophic lateral sclerosis." 



THE NERVOUS SYSTEM. 513 

Transverse or diffuse cord lesions above the lumbar enlargement 
produce usually anaesthesia below the level of the lesion and almost 
invariably relaxation of the sphincters. 

The earliest stages of peripheral neuritis are usually recogniza- 
ble, despite a lively knee-jerk, by the predominant sensory symp- 
toms and the etiology. 

Multiple sclerosis presents, in typical cases, intention tremor 
(see above, page 44), nystagmus (page 16), and staccato speech. 
In atypical cases diagnosis is difficult and cases are often mistaken 
for hysteria. 

Almost any chronic joint disease, except tuberculosis, may be 
associated with increased reflexes. Diagnosis depends on the ab- 
sence of other causes for the increase. 

Other Deep Reflexes. — The Achilles reflex is best obtained by 
having the patient kneel on the seat of a well-padded chair, with 
his feet unsupported, while we strike the Achilles tendon. The 
significance of its absence or increase is practically the same as that 
just given for the knee-jerk, but, since it represents a slightly lower 
position in the spinal cord, it may be affected earlier than the knee- 
jerk in any cord disease which begins at the bottom of the cord and 
travels up. Thus in tabes I have known the Achilles reflex absent 
when the knee-jerk still persisted. 

Ankle clonus occurs in spastic conditions of the legs or in any 
disease which increases the other leg reflexes. It is obtained by 
supporting the patient's leg in a state of such relaxation as can be 
obtained, then suddenly and quickly forcing the foot up as far as it 
will go toward the shin, and holding it in this position. A clonic 
spasm results, which in true ankle clonus persists as long as we 
choose to hold the foot in this position. Spurious clo?ius is obtained 
when only a few contractions occur, the muscle then relaxing. This 
spurious clonus can often be obtained in neurasthenic and hysterical 
states, and has not the significance of true clonus. 

Kernig' *s sign is a reflex contraction of the ham-string muscles, 
obtained by flexing the thigh on the trunk at a right angle (as in 
the ordinary sitting position) and then attempting to extend the 
33 



514 PHYSICAL DIAGNOSIS. 

lower leg. Its motion is arrested about half way between the right 
angle and full extension. 

This reflex is of some value in the diagnosis of meningitis, though 
allowance must be made for the stiffness of old age. The sign is by 
no means pathognomonic, but is of some confirmatory value. 

The deep reflexes of the arms (wrist, biceps, and triceps tendon) 
are obtained by snapping these tendons sharply with the finger. 
Decrease in these reflexes we cannot perceive, since they are only 
obtainable when increased. They are increased in practically the 
same diseases which increase the leg reflexes, and also in some 
chronic joint troubles. 

The jaw-jerk is obtained by asking the patient to let the lower 
jaw drop fully, placing a finger on the chin and percussing that finger 
as in percussion of the chest. 

3. Superficial Reflexes. — A "ticklish" person is one whose su- 
perficial reflexes (skin and muscles) are very lively. ■ Among path- 
ological reflexes of this type : 

(&) The Babinski reflex is the most important. It is a modifica- 
tion or reverse of the normal plantar reflex, which crumples up the 
toes toward the sole of the foot if the skin of the foot is tickled. 

To obtain the Babinski reflex, bare the patient's foot and draw 
the blunt end of a pencil along the inner side of the sole from heel 
to toe with moderate pressure. If the great toe cocks up toward 
the shin, Babinski' s reflex is present. Sometimes one or more other 
toes follow the great toe. 

The reflex is obtained on the paralyzed side in hemiplegia and 
other lesions involving the motor tract. 

(b) The cremasteric reflex draws the testis tight up against the 
body (as after a cold bath) when the skin and muscles on the 
inner side of the thigh are gathered up and firmly grasped in the 
hand. 

(c) The abdominal and epigastric " tickle reflexes " are excited 
by lightly and quickly stroking the skin of these parts with a pen- 
cil point or something of the sort. 

The presence of cremasteric, abdominal, and epigastric reflexes 
indicates that the portion of the spinal cord in which they are rep- 



THE NERVOUS SYSTEM. 515 

resented (upper lumbar and lower dorsal regions) is functionally 
sound. The absence of these reflexes, however, signifies nothing, 
for in many healthy persons they cannot be excited. 

(d) The reflex of winking excited by the ordinary stimuli signi- 
fies the approximately normal conductivity of the fifth and seventh 
nerves (trigeminal and facial). 

4. Sphincteric Reflexes. — The sphincters of the bladder and rec- 
tum are kept closed in the normal adult by reflex contraction ex- 
cited by the presence of urine and faeces. If there is no aware- 
ness of faeces at the anus or of urine at the neck of the bladder, 
owing to destruction of the conducting nerves or spinal nerve-cen- 
tres, involuntary urination and defecation occur. 

This is the case in transverse, diffuse, or compression myelitis 
above the segment (fourth and fifth sacral) where the centres for 
bladder and rectum are represented; l also in tabes dorsalis, dementia 
paralytica, and less often in other chronic spinal diseases. Periph- 
eral neuritis and brain lesions rarely affect the sphincters. 

In deep coma from any cause (epilepsy, cerebral hemorrhage) 
the sphincters may be relaxed, owing to the abolition of sensation. 

5. Sexual Poiuer. — Sexual power may be regarded as a reflex in 
the presence of a particular stimulus, and is diminished or lost in 
chronic cord diseases involving the first and second sacral segments 
(lumbar enlargement) or the nerves leading to them, e.g., in tabes, 
some cases of myelitis and dementia paralytica, etc. Temporary 
increase of power may precede the diminution. 

IV. Electrical Reactions. 

In health a sharp contraction occurs if a faradic current is ap- 
plied to a nerve or over a muscle, and a similar contraction can be 
obtained with the galvanic current just when the circuit is closed 
or broken, but not when the current is passing. 

In contrast with these conditions is the reaction of degeneration. 

1 It must be remembered that these nerves arise from the cord at the level 
of the first lumbar vertebra, though they do not issue from the spinal column 
till the fourth and fifth sacral foramina are reached. 



516 PHYSICAL DIAGNOSIS. 

When this is present we obtain no muscular twitching with the 
faradic current and none over the nerve with the galvanic; but 
with the galvanic over the muscle a slow, worm-like contraction oc- 
curs, and the response to the positive pole is as good as to the neg- 
ative, or better, whereas normally there is far better response to 
the negative. This is the complete reaction of degeneration; in 
partial reactions of degeneration all the normal reactions may be 
present, but diminished in intensity. 

Reaction of degeneration occurs in all diseases affecting the an- 
terior motor horns of the cord or their prolongations downward in 
the peripheral nerves ; for example, in anterior poliomyelitis, pro- 
gressive muscular atrophy, transverse or pressure myelitis, and all 
severe forms of peripheral neuritis. In brain lesions this reaction 
rarely occurs. 

In prognosis a reaction of degeneration persisting after six to 
twelve weeks is unfavorable for recovery of the use of the muscles 
in which it occurs. If reaction of degeneration is absent or partial 
from the start, prognosis is for relatively speedy recovery, weeks 
rather than months. 

V. Speech and Handwriting. 

Aphasia, the loss of the power to speak or understand speech, 
despite normal hearing and muscular powers, occurs in lesions af- 
fecting the third left frontal and first left temporal convolutions 
of the brain. 1 

The lesions producing aphasia may be permanent anatomical 
changes following hemorrhage or tumor, or they may be transitory, 
as in ursemia and migraine. 

The power to write or read letters is lost {agraphia) when the 
angular and supramarginal convolutions are destroyed. 

Degeneration of the handwriting, as compared with the standard 
of former years, is often a helpful bit of evidence in the diagnosis 
of dementia paralytica, but may occur temporarily in various fatigue 
states. 

1 In some left-handed persons the centres are on the right side of the brain. 



THE NERVOUS SYSTEM. 517 



VI. Trophic or Vasomotor Disorders. 

Trophic lesions of the joints, muscles (atrophy), skin, and nails 
have already been exemplified (pages 497 and 52). They blend with 
and are by some explained as the results of vascular changes {vaso- 
motor). Herpes labialis ('''cold sore") and herpes zoster ("shin- 
gles") certainly seem to give every evidence of being due to nerve 
nutritive disorders and not to vascular changes. The acute bedsores 
which form in myelitis, the "angioneurotic" local sivellings which 
appear here and there in certain persons, and the local syncope or 
asphyxia which sometimes lead to Raynaud's form of gangrene, 
seem to need both nerve and vessel changes to explain them. 

In brain lesions these trophic and vasomotor changes are much 
rarer than in disease of the cord and peripheral nerves. 

VII. The Examination of Psychic Functions. 

The diagnosis of the mental factors of disease forms an impor- 
tant part of the study not only of neurology, but of all diseases 
wherever situated; but as it cannot be called physical diagnosis, it 
falls outside the scope of this book, except in so far as loss of con- 
sciousness, coma, may be considered under this heading. 



Coma. 

The causes of coma are identical with the causes of convulsions. 
Every disease which causes the one may cause the other; hence all 
that is here said on the diagnosis of coma applies equally well to 
the diagnosis of convulsions. Either or both may result from : 

1. Apoplexy (including cerebral hemorrhage, embolism, and 
thrombosis). 

2. Uraemia and hepatic toxaemia. 

3. Diabetes. 

4. Cerebral concussion (stun). 

5. Cerebral compression. 



518 PHYSICAL DIAGNOSIS. 

6. Syncope (fainting). 

7. Opium. 

8. Alcohol. 

9. Hysteria. 

10. Epilepsy. 

11. Gas poisoning. 

12. Sunstroke. 

Apoplexy is the probable diagnosis when an elderly person who 
has shown no previous signs of ill-health becomes suddenly and 
deeply comatose within a few seconds or minutes. If hemiplegia is 
present (with or without aphasia) and if we can exclude the other 
causes above mentioned, the probability of apoplexy is increased. 
To determine hemiplegia in a comatose patient, try the following 
tests : 

(a) Lift the arm and then the leg, first on one side and then on 
the other, and let go. The supported member falls more limply on 
the paralyzed side. 

(6) Pinch or prick the limbs alternately. The sound limb may 
be moved, while the other remains motionless. Pressure over the 
supraorbital notch may bring out a similar difference in the response 
of the two sides. 

(c) Try the knee-jerks. On the paralyzed side the jerk may be 
increased. 

(d) Try Babinski's reaction. It may be present on the para- 
lyzed side. 

JJrcemia. — The diagnosis between apoplexy and uramiia is some- 
times impossible, since uraemia may produce hemiplegia and the 
urine in the two conditions (as obtained by catheter) may be identi- 
cal. Usually, however, the uraemic patient has previously shown 
obvious signs of nephritis — oedema, headache and vomiting, long- 
standing oliguria, or polyuria with albuminuria. Convulsions more 
often precede or follow the coma of uraemia than that of apoplexy. 
Retinal hemorrhages or albuminuric retinitis, if recognized by oph- 
thalmoscopic examination, point strongly to uraemia. 

The hepatic toxaemia in which many cases of cirrhosis die is dis- 
tinguishable from uraemia only if the previous history of the case is 



THE NERVOUS SYSTEM. 519 

known to us and the signs of liver disease (ascites, jaundice, caput 
Medusae) are evident. 

Diabetic coma is usually recognized with ease, because the evi- 
dences of advancing diabetes lead gradually up to it. The emacia- 
tion of the patient, the sweetish odor of the breath, the presence of 
sugar, and especially the evidences of acetone and diacetic acid in 
the catheter-urine, are the essential factors in diagnosis. Dysp- 
noea ("air hunger") precedes thecoma in about one-third of the 
cases. 

Concussion (or stun) after a blow usually clears up in a few 
minutes and so presents no difficulty in diagnosis. If the coma 
lasts on for hours ol- days (as it sometimes does) the suspicion 
arises that we are dealing with 

Compression. For this the evidences are : Focal symptoms, 
convulsions, slowing of the pulse, and signs of depressed fracture. 
To determine the latter fact may be impossible without trephining, 
since the inner table of the skull may be broken, while the outer is 
intact. The focal signs to be looked for are paralyses (ocular or 
peripheral). 

Syncope (or fainting) is usually over in a few minutes and so 
betrays its nature, but it must not be forgotten that a slight convul- 
sion may occur just as the patient comes out of coma. No suspi- 
cions of epilepsy need be aroused thereby, but if there have previ- 
ously been signs of hysteria we may be in doubt whether the 
fainting fit is not of hysterical origin. The history of the case, the 
circumstances at the onset of the attack, and the presence or ab- 
sence of hysterical behavior during it usually guide us aright. 

Opium poisoning produces a coma from which the patient can 
usually be more or less aroused. Contracted pupils and slow respi- 
ration are the most characteristic signs. A laudanum bottle or a 
subcutaneous syringe found near the patient often assist the diag- 
nosis. 

Alcoholic coma is rarely complete. The patient can be aroused. 
The circumstances under which he is found, the odor of alcohol on 
the breath, the absence of paralysis, fever, small pupils, or urinary 
abnormalities are the main supports in diagnosis. There is no char- 



520 PHYSICAL DIAGNOSIS. 

acteristie pulse and the pupils show no constant changes, though in 
many cases they are dilated. 

Hysterical coma usually occurs in young women who have pre- 
viously shown signs of hysteria. In falling they never hurt them- 
selves. The eyelids are contracted, often tremulous, and when 
forcibly pulled open often expose eyeballs rolled up so that the 
whites alone are seen. The hands are apt to make grasping motions, 
and there are irregular, semipurposrve movements of various parts 
of the body. A startling word may arouse the patient, but anaes- 
thesia to pain (over one-half or all the body) is often complete. 

Postepileptic coma is usually recognized with ease, because of 
the convulsions which precede it and which are usually known to 
have occurred at intervals before. The scars of previous falls may 
be found on the head. 

Gas poisoning rarely presents any diagnostic difficulties, because 
the circumstances under which the patient is found make clear the 
cause of his condition. An odor of gas may hang about his breath 
for some hours. 

Sunstroke is recognized by the state of the weather and the pres- 
ence of a very high temperature (106°, 110°, 115° F., or even 
more). There is no other characteristic sign. 



APPENDICES. 



APPENDIX A. 

DISEASES OF THE MEDIASTINUM 

I. Mediastinal Tumors. 

New growths of the mediastinal glands 1 usually manifest their 
presence by the following symptoms and signs : 

(1) Cachexia and substernal pain. 

(2) Evidence of pressure against : — 

(a) The gullet. 

(b) The ivindpipe or primary bronchi. 

(c) The large venous trunks. 

(d) Nerves which pass through the mediastinum. 

(e) The subclavian arteries. 
(/) The heart. 

(g) The ribs, clavicle, or sternum. 

(3) Secondary deposits in the cervical or axillary glands. 

(a) By pressure on the gullet swallowing may be rendered diffi- 
cult or impossible (dysphagia). 

(b ) By pressure on the windpipe may be produced displacement 
of the latter to one side, or fixation so that it cannot be moved in 
any direction. The larynx may be drawn down into a noticeably 
low position, and the laryngoscope may demonstrate that the tra- 
cheal wall is bulged inward by the pressure of the new growth 
upon it. 

Pyspnoea, either inspiratory or expiratory, or both, and often 

1 Tuberculous glands not being here included. 



522 PHYSICAL DIAGNOSIS. 

of noisy strident type, may result from stenosis of the trachea 01 
primary bronchi. Owing to pressure on one of the large bronchi, 
the resonance and breath sounds and fremitus may be diminished 
over the corresponding lung, in which finally abscess or gangrene 




Fig. 236— Sarcoma of Mediastinum and Cervical Gland. Vena cava superior obstructed. 

may develop, owing to the retention and decomposition of the 
bronchial secretions. 

(c) If the pulmonary veins are pressed upon, a systolic murmur 
may be audible in the left back, and congestion of the lungs may 
ensue. 

Pressure on the innominate and subclavian veins produces cya- 
nosis or oedema of the head, neck, shoulder, and arm, while the 
superficial veins of the chest may become enlarged and prominent 
owing to an attempt at collateral circulation, especially if the vena 
cava superior is pressed upon. Fluid may accumulate in one or 



DISEASES OF THE MEDIASTINUM. 523 

both pleural cavities if the vena azygos or thoracic duct is in- 
volved (see Fig. 236). 

{d) Aphonia or hoarseness points to pressure on the recurrent 
laryngeal nerve, and on laryngoscopic examination one vocal cord 
may be found in the cadaveric position. Inequality of the pupils, 
due to pressure on the sympathetic nerves, is not uncommon, and 
severe pain along the distribution of the intercostals or running 
down the arm indicates that the spinal ganglia or brachial plexus 
are pressed upon. Much rarer are symptoms of pressure on the 
vagus (slowing or quickening of the heart) and on the phrenic 
nerve (hiccup, unilateral spasm, or paralysis of the diaphragm). 

(e) Weakening or delay in one radial pulse may be due to press- 
ure on the subclavian artery. 

(/) Occasionally the heart itself may be pushed out of place. 

(c/) Pressure of the new growth against the bones of the chest 
may give rise to an area of percussion dulness under or near the 
manubrium, which, however, is not likely to show itself until late 
in the course of the disease when the new growth has reached a 
considerable size. In many cases there is tympanitic resonance in- 
stead of dulness over the affected area. The ribs or sternum may 
be pushed forward, but this is not usually the case. Occasionally 
the new growth, if very vascular, may pulsate like an aneurism or 
transmit the pulsations of the heart to the chest wall, and a systo- 
lic murmur may be heard over the pulsating area, so that the resem- 
blance to aneurism is increased. 

Differential Diagnosis. 

Mediastinal tumors may be mistaken for 

(1) Aneurism of the aortic arch. 

(2) Syphilitic stenosis of a bronchus. 

(3) Phthisis. 

Aneurism may be confounded with mediastinal new growths 
even by the most competent observers. Tactile thrill, diastolic 
shock, and tracheal tugging, if present, should suggest aneurism. 
If these signs are absent, aneurism may still be present but cannot 



524 PHYSICAL DIAGNOSIS. 



be surely diagnosed. The degree of anaemia and emaciation is usu- 
ally greater in malignant disease than in aneurism, but this is not 
always the case. The presence of secondary nodules in the neck or 
armpit speaks strongly in favor of new growth. 

Stenosis of a bronchus, due to syphilis and giving rise to dysp- 
noea, cough, stridor, pulmonary atelectasis, may be very difficult to 
distinguish from mediastinal growth, but the degree of ansemia and 
emaciation is usually less in syphilis, and the beneficial results of 
antisyphilitic treatment may render the diagnosis possible, espe- 
cially if there is evidence of syphilis elsewhere in the body or in 
the history of the case. 

Phthisis may be suggested by the weakness, emaciation, and 
persistent cough produced by mediastinal growths, but should be 
easily excluded by the examination of the lungs and sputa. 

II. Mediastixitis. 

The acute suppurative forms of this rare disease do not give rise 
to any characteristic physical signs in the chest. 

The evidences of chronic fibrous mediastinitis have been already 
sufficiently considered in connection with adhesive pericarditis. 

III. Tuberculosis of the Mediastinal Glaxds. 

Probably every case of pulmonary tuberculosis is preceded or 
accompanied by tuberculosis of the bronchial lymph glands, and in 
numberless cases the tuberculous process never gets beyond these 
glands but is choked off there. In post-mortem examinations of 
children, no matter what the cause of death, it is exceptional not 
to find the bronchial glands tuberculous. 

Nevertheless the disease can but rarely be recognized during 
life. "We may suspect it if, in a child showing tuberculous cervical 
glands or phthisis, we find evidence of pressure upon the right 
bronchus, increased tactile fremitus above the manubrium, lateral 
displacement of the trachea, or weakening of the pulse during in- 
spiration. If a bronchus is compressed, the resonance, tactile 






ACUTE ENDOCARDITIS. 525 

fremitus, and breath sounds are diminished over the correspond- 
ing lung. Wiederhofer lays stress upon an increase in the inten- 
sity of the expiratory murmur over the situation of the left primary 
bronchus. 



APPENDIX B. 
ACUTE ENDOCARDITIS. 

Whether the disease be of the benign or of the malignant (sep- 
tic) type, the results of physical examination of the heart are usu- 
ally very equivocal. We may guess that endocarditis is present 
owing to the presence of a cause (rheumatism), of a fever not oth- 
erwise explained, of a rapid irregular pulse of low tension, but the 
physical signs over the heart will not usually assist our guess ma- 
terially. 

Murmurs are often present but have usually the characteristics 
of "functional" murmurs (systolic, limited, soft, without accentu- 
ation of the pulmonic second sound or cardiac enlargement). If 
we can observe the advent of a diastolic murmur in such a case, we 
may fairly attribute it to a fresh endocarditis of the aortic (very 
rarely of the pulmonic) valve, but if we have not had the oppor- 
tunity to examine the heart previous to the onset of the present 
attack it is impossible to exclude a long-standing valvular lesion as 
the cause of the murmur. 

If murmurs come and go from day to day, or suddenly increase 
in intensity, we may suspect an acute endocarditis, especially if a 
musical murmur is present or if there be evidence of embolism. 

Inspection, palpation, and percussion usually yield no signs of 
importance. There is no enlargement of the heart, no accentuation 
of the second sounds, and no evidence of stasis. 



526 PHYSICAL DIAGNOSIS. 

APPENDIX C. 

PHYSICAL EXAMINATION OF THE CHEST IN INFANTS. 

(1) Tactile fremitus and voice sounds can be investigated only 
in case the child cries or crows. The cry-sound is intensified over 
solidified areas and may or may not be lost over fluid accumula- 
tions. 

(2) Percussion must be very delicately performed if we are to 
avoid setting the whole chest in vibration with every stroke. It is 
best to strike wholly with the finger, keeping the hand (as well as 
the wrist and arm) unmoved. 

(3) In listening to an infant's lungs patience and concentration 
are essential. The child is apt to stop breathing when the exami- 
nation begins, and we have to wait patiently to catch the long-de- 
layed inspiration "on the wing," as it were, before the long expi- 
ratory wail begins. The inspiration, when it does come, is unusu- 
ally intense owing to the thinness of the chest in infancy. 

(4) Long flexible rubber tubes connecting the chest-piece of the 
stethoscope with the ear-pieces are very convenient when examin- 
ing a wriggling child (see Fig. 83, p. 117), as they make it possible 
to hold the chest-piece in position despite the constant movements 
of the struggling sufferer. 

(5) It is advisable to examine first the back while the child is 
held in the mother's arms with its back to the physician. 

(6) Children almost always cry if made to lie down flat. If 
we wish to bring out the cry sound in order to test the vocal and 
tactile fremitus, this is a simple and humane method of producing 
it. If, on the other hand, peace is what we most desire, it is best 
to avoid putting the child in a recumbent position. 

(7) There is no type of breathing peculiar to children or in- 
fants. Puerile breathing is simply vesicular breathing heard very 
distinctly on account of the thinness of the chest. If, in a healthy 
child, the expiratory murmur is prolonged and high-pitched, this is 
probably because the child blows out the breath forcibly in the 
effort to breathe deeply as it is told to do. A young infant never 



RADIOSCOPY OF THE CHEST. 527 

does this, and its breathing is like that of adults except that it is 
more rapid, more irregular, and better heard. 



APPENDIX D. 

RADIOSCOPY OF THE CHEST. 

Radioscopy gives assistance in the diagnosis of diseases of the 
chest in two ways : 

1. Through the use of the fluoroscopic screen. 

2. Through the use of radiographs. 

Those who are accustomed to the use of the nuoroscope gain 
far more information from it than from radiographs, but the record 
of the photographic plate is objective, permanent, and demon- 
strable, while the impressions gained from the nuoroscope are more 
apt to be modified by the personal equation. 

For the present, therefore, we need both methods. 

I shall not attempt to discuss the advantages of the various 
forms of apparatus used for producing Eoentgen rays in a Crookes 
tube ; the subject would carry me beyond my depth as well as be- 
yond the limits of this book ; but whatever form of instrument is 
used, the vacuum in the tube should be less perfect when we desire 
to use it for the chest than when searching for foreign bodies or 
studying fractures. We need a "low " or "soft " tube which gives 
rays of a relatively slight degree of penetration. With high pene- 
tration rays the outlines of the solid organs are less distinct because 
the rays traverse the heart and liver almost as easily as they do the 
lungs. If the penetrating power is less, the rays are arrested by 
the solid organs, but not by the lungs, and hence the outlines of the 
former become visible. 

i". The Use of the Fluoroscope. 

1. It is advisable to remain in a dark room or to wear smoked 
glasses for a short time before attempting to use the fluoroscope. 
This applies especially to beginners. Skilled observers do not need 



528 PHYSICAL DIAGNOSIS. 

such preparation of the retina, but many novices who complain at first 
that they can " see absolutely nothing " when they apply the fluoro- 
scope to the chest, find their vision suddenly and permanently im- 
proved after fifteen minutes in a dark room. Practice increases our 
powers with the fluoroscope as much as it does with the micro- 
scope, and it is unreasonable to expect to see from the first all that 
an expert sees. 

2. The patient should be placed at least two feet from the tube, 
else there is likely to be distortion and magnification of the shad- 
ows corresponding to the organs examined. The tube should be 
placed at such a height as to be opposite the most important object 
to be examined, and always in the median line. 

3. Patients may be examined either in the upright position — 
the tube about two feet from the patient's back — the fluoroscope 
resting against the chest — or in the recumbent position, supported 
on a canvas cot with the tube underneath. I prefer the upright 
position. The patient's arms should always be extended forward 
so as to get the scapulae out of the way. 

4. To concentrate the light upon a spot of special interest, we 
may use a metal plate with a rectangular opening about two by 
three inches near one end. When this plate is held between the 
tube and the patient, so that the opening is opposite the spot to 
be examined, the rays pass through the opening, but are intercepted 
by the metal around it. The hand which holds this plate should 
be protected from the action of the rays. 

5. To mark on the chest the outlines of the shadows seen with 
the fluoroscope, a pencil enclosed in a tube of brass is useful ; the 
brass jacket makes the pencil visible and enables us to adjust its 
point to the outlines on the chest. An ordinary pencil is pene- 
trated by the rays completely, and it is hard to draw with a pencil 
which we cannot see. 

II. The Normal Fluoroscopic Picture (see Frontispiece). 

The lungs appear as the lightest part of the field owing to the 
large amount of air they contain ; at the end of full inspiration, 
they become still lighter. Against the light lung areas, the out- 



RADIOSCOPY OF THE CHEST. 529 

lines of the ribs and of the vertebral column (with the sternum super- 
imposed) are clearly visible. Less clear, but usually quite distin- 
guishable, are the outlines of the heart and the upper border of the 
liver. A slight shadow (see Fig. 174) is often noticed just to the 
right and to the left of the heart in a position corresponding to the 
larger bronchi. The spleen is not usually to be made out clearly, 
but the upper surface of the diaphragm above it is generally visible. 
The contractions of the heart and the movements of the diaphragm 
are usually clear, and any restriction of the respiratory excursion 
on one side can be noted, though the fluoroscope has no advantages 
over the inspection of Litten's diaphragm shadow (see p. 76) for 
this purpose. 

Abrams has noted that if the skin of the precordia is irritated 
by cold or pain, a reduction in the size of the heart occurs ("heart 
reflex") for a few seconds. 

In children all these phenomena are especially clear, owing to 
the thinness of their chest walls and we note at once how much 
more horizontal the child's heart is than the adult's. 

III. The Fluoroscope iw Disease. 

I shall mention first those diseases in which the fluoroscope fur- 
nishes us the most valuable information. 

1. Aneurism. — Small aneurisms of the transverse or descending 
aorta may sometimes be recognized by the se-rays when no other 
method of physical examination yields satisfactory evidence. An 
abnormal shadow appears at one side of the sternum (see Fig. 237) 
and may sometimes be seen to pulsate. In other cases the fluoro- 
scopic evidence is not the only evidence, but tends to confirm or 
dispel suspicions aroused by the ordinary methods of examination. 

Aneurism of the heart itself is recognizable, according to F. H. 
Williams, by the fluoroscopic examination. No other method of 
examination gives us any evidence of such a lesion. 

2. Determination of the Cardiac Outlines in Patients with Em- 
physema and Fat Chest Walls. — Emphysema spoils cardiac percus- 
sion and interferes with inspection and palpation. But in fluoro- 

34 



530 



PHYSICAL DIAGNOSIS. 




Fig. 237.— Radiograph of Thoracic Aneurism, 



RADIOSCOPY OF THE CHEST. 531 

scopic work emphysema is a boon and a blessing, for it renders the 
cardiac outlines more distinct than usual. Hence, for determining 
the size and position of the heart in such cases, the arrays give 




Fig. 238.— Right-sided Pneumothorax seen from Behind. The collapsed right lung is seen 
against the spinal column and surrounded by an unnaturally bright area corresponding to 
the empty thoracic cavity. The shadow of the heart appears vaguely on the left side of the 
spine. 

genuine assistance, as they also do when mapping out the heart in 
women with large breasts and fat chest walls. 

3. Cemtral Pneumonia. — Williams and others have succeeded 
in identifying foci of solidification beneath the surface of the lungs 
when no other physical signs could be obtained. It must be re- 



532 PHYSICAL DIAGNOSIS. 

membered, however, that congestion of the lung, oedema, atelec- 
tasis, and pleural thickening produce shadows similar to those of 
solidified lung. 

4. Tuberculosis. — It is still a matter of doubt whether tubercu- 
lous foci can be recognized by the fluoroscope before the disease has 
progressed sufficiently to produce localized rales, diminished breath 
sounds, or restriction of Litten's phrenic phenomenon. 

Slight opacities have been noted in cases which later turned out 




Fig. 239.— Aneurismal Sac, Radiographed from Behind. 

to be tuberculosis, and which had not previously been diagnosed, 
but the shadows perceived by the fluoroscope are capable of many 
interpretations and correspond (as above said) to various patholog- 
ical conditions. Old quiescent foci may appear like advancing le- 
sions and thus lead to serious errors. We do not want to hurry a 
patient off to Colorado or Davos on account of the shadow thrown 



RADIOSCOPY OF THE CHEST. 



533 



by a long-healed lesion. Further, in some cases of rheumatism, 
anaemia, debility, and convalescent typhoid, appearances very simi- 
lar to those of tuberculosis may be found (Williams). Hence the 
interpretation of slight lung shadows in cases of suspected incipient 
phthisis is by no means easy. 

Advanced phthisis renders the lungs relatively opaque to the 



Aneurismal sac. 



Heart. 




Fig. 240.— Aneurismal Sac Radiographed from Behind. 



Roentgen rays except where extensive excavation has occurred ; 
here we see a light area in a dark background. 

No satisfactory radiographs of cases of incipient phthisis have 
so far been published, so far as I am aware. 

5. Pleuritic Effusions. — The displacement of the heart is some- 
times better shown by the cc-rays than by ordinary methods of ex- 
amination, since the compensatory hypertrophy of the sound lung, 



534 PHYSICAL DIAGNOSIS. 

which interferes with percussion and palpation of the heart, renders 
radioscopy easier. 

The fluid exudate intercepts the rays perceptibly, and when the 
movements of the diaphragm are not abolished on the affected side, 
the line corresponding to the surface of the fluid can be seen to 
move up and down with respiration. 

Small fluid accumulations flatten the normal curve of the upper 
surface of the diaphragm by filling up the chink between the inner 
surface of the chest in the axilla and the line of the diaphragm at 
that point. 

6. Emphysema. — The lungs become unusually transparent and 
owing to the low pocition of the diaphragm the heart descends and 
assumes a very vertical position ("ptosis of the heart"); these 
points are very clearly seen with the fluoroscope. 

Radiographs. 

But little use has thus far been made of radiographs in study- 
ing diseases of the chest. The movements of the heart, of the 
chest walls, and of the diaphragm render all the outlines indistinct. 
For aneurisms, especially those containing a thick layer of clot, and 
for intrathoracic tumors, radiographs may be very useful, and 
bronchial lymph glands are sometimes rendered visible. 



APPENDIX E. 
THE SPHYGMOGRAPH. 

This instrument consists of a system of levers by means of which 
the pulsations of the radial artery are transferred to a needle whose 
oscillations can be graphically recorded upon a piece of smoked pa- 
per. It is a very fascinating little toy, but in its present form is 
almost devoid of practical usefulness owing to the impossibility of 
eliminating the personal equation when using it. The size and, to 
a certain extent, the shape of the wave traced upon the smoked 
paper can be influenced at will by the amount of pressure with 
which the instrument is applied to the wrist. If an instrument is 



THE SPHYGMOGRAPH. 535 

applied with a pressure of three ounces to the wrist of A, aud then 
with the same pressure to the wrist of B, the force exerted upon 
the artery may be quite different in the two cases owing to the dif- 
ferent shape of the wrist in the two individuals. 

Almost any type of tracing can be obtained from a normal pulse 
by varying the pressure. 

This objection is fatal to the use of the sphygmograph as an in- 
strument of precision, and although it is capable of recording tiny 
secondary waves impalpable by the fingers, it has yet to be shown 
that it reveals anything of practical diagnostic value which is not 
appreciated by skilled fingers. For these reasons I have given no 
account of the instrument in the body of this work. 



INDEX. 



Abdomen, contour of, 363 

distended and tortuous veins of, 

363 
inspection of, 362 
marking of, 363 
methods of examination, 362 
organs palpable in, 366 
palpation and percussion of, 

362 
palpation, methods of, 364 
projection or levelling of navel, 

363 
respiratory movements of, 364 
rose spots on, 363 
tumors of, 368 
tumors of, diagnosis from tumors 

of wall, 368 
tumors of; observation of, 368 
tumors of, respiratory mobility 

in, 368 
tumors of, with ascites, 368 
tumors of, with jaundice, 368 
tumors of, with leukaemic blood, 

368 
Abdominal reflexes, 514 
wall, abscess of, 367 
wall, actinomycosis of, 367 
wall, infected haematoma of, 367 
wall, sarcoma of, 367 
wall, tuberculosis of, 367 



Abscess, alveolar, 25 

cold, 55, 69 

cervical, in Pott's disease, 31 

in tuberculous arthritis, 492 

ischio-rectal, 441 

of abdominal wall, 367 

of appendix, psoas spasm in, 493 

of brain, optic neuritis in, 16 

of glands near urethra, 447 

of hip-joint, 455 

of liver, 352, 388 

of lung, breath in, 21 

of tonsil, 28 

perinephritic, 54, 416 

perinephritic, psoas spasm in, 
493 

peri-urethral, 443 

psoas, 55, 453, 455 

diagnosis from actinomyco- 
sis, 55 

pulmonary, 357 

retropharyngeal, 28 

tuberculous, 55 
Acetone breath, 21 
Achilles reflex, test for, 513 

tendon, tenosynovitis, 461 
Achromia of red cells, in chlorosis, 

476 
Achylia gastrica, stomach contents 
in, 380 



537 



538 



INDEX. 



Acid urine, 423 

Acne, eruptions on forehead in, 9 

nose in, 17 
Acromegalia, 8, 9, 40 

chin in, 10 

face in, 8, 9 

family likeness in, 9 

feet in, 47 

hands in, 47 

nose in, 10, 17 

prominent cheek bones in, 10 

ridges above eyes in, 10 

"whopper- jaw" in, 10 
Actinomyces of belly-wall, 367 
Actinomycosis of neck, 34 
Acute dyspnceic conditions, depressed 
fontanels in, 7 

endocarditis, 525 

fevers, loss of hair in, 7 
Addison's disease, buccal patches in, 

26 
Adenitis, 29, 94, 95, 521 
Adenoids, 10 

and thoracic deformity, 60 

breathing in, 11 

face in, 10, 11 

mouth in, 10, 18 

nose in, 17 

snoring in, 11 

tonsils in, 28 
Adherent pericardium, 276 
Agraphia, 516 
Albuminuria, Esbach's test for, 424 

in local peritonitis, 371 

in peritonitis, 371 

significance of, 425 

test for, 424 

with nephritis, 426 

without nephritis, 425 
Alcoholism, ataxia in, 508 

breath in, 21 



Alcoholism, coma in, 519 

distribution of fat in, 12 

exaggerated pharyngeal reflex in, 
29 

face in, 12 

nose in, 12, 17 

paralysis in, 36, 456 

shaking of head in, 13 

tongue in, 22 

tremor of hands in, 44 

vomiting in, 29 

with fatty liver, 387 
Alkaline urine, 423 
Alopecia areata, patchy baldness in, 

7 
Amoeba coli, 405 

coli, in faeces, 405 
Amphoric breathing, 161, 313, 322 
Amyloid disease, spleen in, 412, 414 

liver, 388 
Amyotrophic lateral sclerosis, 512 
Anaemia, ascites in, 372 

blood in, 470 

diagnosis of, 14 

in cancer of peritoneum, 372 

in cancer of stomach, 382 

in tuberculosis of peritoneum, 
372 

cedema of eyelids in, 14 

of nails, 52 

pernicious, blood in, 476 

retinal haemorrhage in, 16 

secondary, blood in, 475 

secondary, causes of, 476 
Anaesthesia, hysterical, 510 

in neuritis, 36 

tests of, 509 
Anatomy of chest, 56 
Aneurism, 54, 280-291 

abdominal, 366 

abnormal pulsation in, 86, 87, 280 



INDEX. 



539 



Aneurism, auscultation in, 285 
diagnosis of, 288, 289 
diastolic shock in, 282 
diffuse, 280, 289 

distinguished from aortic steno- 
sis, 289 
distinguished from diffuse dilata- 
tion of the arch, without rup- 
ture of coats, 289 
distinguished from empyema ne- 
cessitatis, 290 
distinguished from mediastinal 

tumors, 290 
emaciation in, 2 
percussion signs in, 284 
pressure symptoms in, 284 
radioscopy in, 287, 528 
thoracic, 280, 291 
thrill in, 282 
tracheal tug in, 283 
tumor in, 281 
with contracted pupil, 15 
Angioneurotic local swellings, 517 
oedema of lip, 19, 20 
oedema, symptoms of, 14 
Ankle clonus, test for, 513 
epithelioma of, 461 
jerk, test for, 513 
tuberculosis of, 461 
Ankylosis, following atrophic arthri- 
tis, 497 
Anorexia in local peritonitis, 371 

nervosa, malnutrition in, 2 
Anterior poliomyelitis, acute paralysis 
in, 36 
poliomyelitis, knee-jerk in, 

512 
poliomyelitis, reaction of degen- 
eration in, 516 
Anus, fissure of, 441 
fistula of, 441 



Aorta, aneurism of, pointing in back, 
54 

normally palpable, 366 
Aortic aneurism, 86, 280 

disease, 229, 246 

obstruction, see Stenosis 

pulsation (dynamic), 86 

regurgitation, 229-239 

regurgitation, complication of, 
238 

regurgitation, diagnosis of, 237 

regurgitation, murmurs in, 235 

regurgitation, pulse in, 232, 233 

regurgitation, signs, 230 

regurgitation, sounds in, 236, 
237 

roughening, 238 

second sound, 179 

stenosis, 239-246 

stenosis, diagnosis of, 243-245 

stenosis, murmurs in, 240 

stenosis, pulse in, 242 

stenosis, signs in, 240-246 

stenosis, thrill, 243 
Apex beat, see Cardiac Impulse 

cardiac, see Heart 

retraction, 84 
Aphasia, 516 
Apncea, in Cheyne-Stokes breathing, 

74 
Apoplexy, 75 

coma in, 518 

distinguished from uraemia, 518 
Appendicitis, cause of peritonitis, 371 

diagnosis of, 400 

local and constitutional signs in, 
399, 400 

muscular spasm in, 400 

psoas spasm in, 493 

simulated, 400 

tumor in, 400 



540 



INDEX. 



Appendix in palpation, 366 
Arcus senilis, 16 

senilis in arteriosclerosis, 16 

senilis in old age, 16 
Argyll-Robertson pupil, 15 
Arm, 35 

contractures of, 37 
Arms, deep reflexes of, 514 

fatty tumors of, 38 

gouty deposits in, 38 

in Paget's disease, 40 

in rickets, 40 

cedema of, 38 

cedema of, in Hodgkin's disease, 
38 

cedema of, in inflammation, 38 

cedema of, in nephritis, 38 

cedema of, in sarcoma of lung, 38 

cedema of, in sarcoma of medias- 
tinum, 38 

cedema of, in thrombosis, 38 

cedema of, with tumors, 38 

paralysis of, 35 

sarcoma of bone of, 38, 39 

syphilitic nodes in bone of, 38 

tuberculosis of bone of, 38, 40 

tuberculous lesions of, 39 

wasting of, 37 
Arrhythmia, 263 
Arsenic poisoning, neuritis in, 456 

poisoning with conjunctivitis, 14 
Arterial movements, 89 

murmurs, 198 

pressure, 111-117 

pressure, diastolic, 108, 116 

pressure, methods of measuring, 
111 

pressure, systolic, 106, 114 

pulsations, 89 

sclerosis, 90 

sounds, 182 



Arterial tension, 108, 109, 111 

walls, calcification of, 110 
Arteries, auscultation of, 237 

calcification of, 110 

diseases of, 110, 280 

inspection of, 89 

murmurs in, 198, 237 

position of, 109 

size of, 109 

stiffening of, 110 

tuberosity of, 90 
Arteriosclerosis, arcus senilis, 16 

gangrene of toe in, 463 

hot feet in, 462 

paresthesia in, 510 
Arthritis, acute infectious, distin- 
guished from other types, 493 

acute infectious, endocarditis in, 
495 

acute infectious, results of, 495 

acute infectious, signs in, 495 

atrophic, 47-50, 494, 497, 496 

atrophic, changes in wrist, 47 

atrophic, flipper-hand in, 46, 47 

atrophic, Morvan's disease in, 50 

distinguished from acute osteo- 
myelitis, 454 

dysenteric, 493 

gonorrhceal, 493 

gouty, 501 

haemophilic, diagnosis of, 503 

hypertrophic, features of, 498 

hypertrophic, Heberden's nodes 
in, 47-50 

hypertrophic, of sacro-iliac joint, 
53 

hypertrophic, psoas spasm in, 
493 

hypertrophic, with kyphosis, 54 

infectious, 492 

infectious, inguinal glands in, 453 



INDEX. 



541 



Arthritis, influenzal, 493 

pneumococcic, 493 

syphilitic, 493 

tuberculous, 492 
Ascaris lumbricoides, 405, 409 
Ascites, 370, 372 

Asphyxia, local, in Raynaud's dis- 
ease, 49 
Astereognosis, 509 
Asthma, 322 

bronchial, 322 

bronchial, blood in, 479 

diagnosis of, 322 
Asthmatic breathing, 74, 322 
Ataxia, causes of, 372 

forms of, 508 

respiratory movements of belly 
in, 364 

Romberg's sign in, 509 
Atelectasis, 66, 73, 163, 359 

crepitant rales in, 163 
Athetosis, 45, 508 

Atrophic arthritis, ankylosed stage in, 
497 

arthritis, deformities in, 498 

arthritis, monarticular form, 497 

arthritis, polyarticular form, 
symmetrical involvement of 
joints in, 497 

arthritis, primary polyarticular 
form, 497 

arthritis, types of, 494, 496, 497 

arthritis, a>ray of hand in, 494 

diseases of wrist-joint, 40 
Atrophy following fracture or dislo- 
cation, 37 

in hysteria, 37 

muscular claw-hand in, 46 

of disuse, 37 

progressive muscular, fibrillary 
twitching in, 508 



Atrophy, progressive muscular, 
wasting of arm in, 37 

trophic, 37 
Auscultation, 137, 198. (See also 
Breathing and Murmurs. 
Rules. Heart sounds.) 

mediate vs. immediate, 137, 138 

of heart, 171, 198 

of lungs, 149-170 

of muscle sounds, 146 

sources of error in, 146-149 

technique of, 143-146 

Babinski's reaction, in paralysis, 
518 

reflex, test for, 514 
Back, 53, 66 

aneurism pointing in, 54 

dermoid cyst of, 55 

epithelioma of, 55 

in lumbago, 53 

lipomata of, 55 

perinephritic abscess of, 54 

spina bifida of, 55 

stiffness of, 53 

tumors of, 54 
Bacteria in faeces, method of exami- 
nation for, 404 
Balanitis, 443 
Balantidium coli, 405 
Baldness, hereditary, 7 

in trigeminal neuralgia, 7 

patchy, in alopecia areata, 7 

patchy, in skin disease, 7 
Barrel chest, 64, 318 
Baths, cold, leucocytosis in, 478 
Belly, in cretinism, 10 

in general peritonitis, 37 

wall, hernia in, 367 

wall, lesions of, 367 
Biceps, rupture of, 38 



542 



INDEX. 



Bile in blood, 14 

in urine, 14 
Bile-ducts, 393 
Bilharzia disease, blood in, 479 

haematobium, 405, 410 
Biliary colic, 417 

colic, differential diagnosis of, 393 

obstruction, 14 
Bladder data, 437 

diseases of, urine in, 439 

distention of, 437 

distention of, causes of, 438 

paralysis of, retention of urine in, 
439 

statistics on, 437 

stone of, 439 

tuberculosis of, 440 

tumors of, retention of urine in, 
439 

tumors of, urine in, 423 
Blindness, dilatation of pupil in, 15 
Blood, appearance when stained, 469 

coagulation time in, 485 

color index of, 466 

counting red corpuscles, method 
of, 474 

counting white corpuscles, meth- 
od of, 473 

cover-glass preparation of, 468 

eosinophilia in, 478 

examination of, 464 

examination of stained, 467 

haemoglobin tests, 464-466 

in chlorosis, 476 

in fieces, 403, 404 

in lymphatic leukaemia, 479 

in pernicious anaemia, 476 

in secondary anaemia, 475 

interpretation of result of leu- 
cocyte count and differential 
count, 477 



Blood, in vomitus in gastric cancer, 
382 

in whooping-cough, 479 

leucocytes in, 471 

leucocytosis in, 478 

lymphocytosis in, 478 

normoblasts distinguished from 
megaloblats in, 470 

nucleated red cells in, 470 

parasites in, 482 

percentages of white cells in, 471 

platelets in, 472 

poikilocytosis, 470, 475 

polychromasia, 470, 475 

preparation of film, spreading, 
467 

pressure, see Pressure 

staining of, 467 

stains used, 469 

stippled red cells in, 470 

test for, 379 

Widal reaction, 481 
Body, as a whole, 1 

fluid in, 1 

weight of, 1 
Bone, destruction of, in atrophic 

arthritis, 496 
Bones in acromegalia, 10 
Bony nodes of forehead, 8 
Bow-legs, 458 
Bradycardia, 262 
Brain, abscess of, optic neuritis in, 16 

diseases of, transient glucosuria 
in, 427 

lesions of, hemianaesthesia in, 510 

paralysis of, 506 

paralysis of, mental changes in, 
507 

tumors of, optic neuritis in, 16 
Branchial cyst, 33, 34 

fistulae, congenital, 34 



INDEX. 



543 



Breast, funnel, 62 

pigeon, 62, 65 (see also Chest) 
Breath, acetone, 21 

foul, 21 

in alcoholism, 21 

in foul teeth and gums, 21 

in gastric fermentation, 21 

in poisoning by illuminating gas, 
22 

in starvation, 21 

in stomatitis, 21 

in syphilis, 21 

in typhoid fever, 21 

in uraemia, 21 
Breathing, amphoric, 161 

asthmatic, 69, 74, 155 

bronchial, 153, 160 

broncho vesicular, 160 

catchy, 75 

cavernous, 161 

Cheyne-Stokes, 74 

Cheyne-Stokes, causes of, 75 

cogwheel, 156 

compensatory, 157 

costal, 69 

diaphragmatic, 69 

difficult, 71 

diminished, 71 

emphysematous, 155 

exaggerated vesicular 153, 157 

grunting, 75 

interrupted 156 

irregular, 75 

metamorphosing, 156 

normal, 69, 72 

puerile, 153 

rapid, 71, 72 

restrained, 75 

rough, 153 

shallow, 75 

sighing, 76 



Breathing, stertorous, 75 

stridulous, 74, 76 

tracheal, 153, 154, 160 

tubular, 153, 160 

types of, 74 

vesicular, 151 

(see also Respiration) 
Brodie Russell coagulometer, 484 
Bronchi, dilatation of (see Bronchiec- 



diseases of, 292, 296, 322-324 

stenosis of, 523 
Bronchial asthma, 294, 320, 322 

breathing (see Breathing) 
Bronchiectasis, 323 
Bronchitis, 292 

acute, 292 

chronic, 40, 47, 295, 320 

diagnosis, 294 
Bronchophony, 168 
Bronchopneumonia, 303 
Bronchovesicular, 160 (see Breathing) 
Buccal cavity, 25 

cavity, gangrene of, 26 

cavity, in Addison's disease, 26 

cavity, pigmentations in, 26 
Bulging of interspaces, 68 

of one chest, 68 
Bursitis of prepatellar bursa, 458 

"Cachexia" of old age, 2 
Calcaneus, 460 
Calculus, biliary, 391 
Cancer, gastric, 2 

gastric, advanced, symptoms, 
382 

gastric, malnutrition in, 2 

gastric, statistics of, 382 

gastric, tumor in, 375 

gastric, with absence of hydro- 
chloric acid, 382 



544 



INDEX. 



Cancer, metastatic, of thigh, 455 

metastatic, with pressure on 
cord, paraplegia in. 457 

obstruction of gall-duct in, 394 

of chest wall, 358 

of intestines, signs and symptoms 
of, 402 

of liver, 387 

of lung, 67, 358 

of pancreas, jaundice in, 394, 395 

of penis, 444 

of peritoneum, 370, 372 

of peritoneum, anaemia in, 372 

of peritoneum, ascites in, 372 

of peritoneum, diagnosis of, 372 

of peritoneum, emaciation in, 372 

of peritoneum, signs of, 372 

of peritoneum, tumors in, 372 

of pleura, 353, 358 

of rectum, 442 

of sigmoid, 402 

of testis, 444 

of thyroid gland, 32 

of tongue, 22 

of uterus, 448 

with enlarged cervical glands, 
30 
Canker of tongue, 22 
Capillary pulse, 52, 91, 232 
Cardiac disease, ascites in, 372 (see 
also Heart) 

disease, diuresis in, 1 

disease, dropsy in, 1 

disease, sweating in, 1 

disease, weight in, 1 

hypertrophy (see Hypertrophy) 

impulse, character of, 79 

impulse, displacement of, 66, 79, 
203, 205, 208, 210, 231, 243, 
277, 334, 343 

impulse, normal, 79 



Cardiac murmurs, 184-198 (see 
Murmurs) 
movements, 203, 257, 261-265 
neuroses, 261-265 
neurosis, arrhythmia in, 263 
neurosis, bradycardia in, 262 
neurosis, palpitation in, 264 
neurosis, tachycardia in, 261 
outlines, 57, 205-208, 530 
sounds, 172 

Caries of vertebrae, abscess in, 28 

Carphologia, 43 

Cartilage, destruction of, in atrophic 
arthritis, 496 

Casts in urine, 429 

Cavernous breathing, 313 

Cavity, pulmonary, 313 

Cervical rib, an accessory, 34 

Chancre of lip, 19 

Chancroids, inguinal glands in, 452 

Charcot's joint, atrophic arthritis in, 
496 
joint, motility in, 491 

Cheek bones in acromegalia, 10 

Chest, anatomy of, 56 

auscultation of, 137-170 
barrel-shaped, 64 
deficient expansion, 70 
deformities, 60, 64, 66 
examination of, 60, 361 
examination of, in infancy, 525 
expansion, anomalies of, 69 
expansion, diminished, 70 
expansion, "en cuirasse," 74 
expansion, increased, 71 
flattening of, 66 
fluctuation in, 350 
fluoroscopic, 527 
in adenoid disease, 60 
inspection of, 60 
landmarks of, 56, 66 



INDEX. 



545 



Chest, local depression, 61, 62 

local prominences, 67 

movements of, 69-76 

palpation of, 96-103 

phthisical, 63, 67, 304-316 

prominence, local, 68 

prominence of one side, 67 

rachitic, 60, 62, 63 

radioscopy of, 350 

retraction of, 73 

shape of, 61-66 

size of, 60 

surface of, 91-96 

tenderness in, 102 

wall, cancer of, 358 

wall, nutrition of, 65, 93 
Cheyne-Stokes breathing, 75 
Chickenpox, throat in, 27 
Chilliness, diagnosis from chill, 4 
Chills, 3, 4 

after infusion of salt solution, 4 

after or during labor, 3 

after passage of catheter, 3 

determination of etiology, 4 

diagnosis from chilliness, 4 

of acute infections, 3 

of malaria, 3 

of "nervous" states, 3 

of sepsis, 3 
Chin in acromegalia, 10 
Chlorosis, blood in, 476 
Cholangitis, suppurative, 388 

symptoms in, 392 
Cholecystitis, cause of peritonitis, 371 

results of, 395 

signs of, 394 
Chorea, 13 

leg in, 457 

post-hemiplegic, 45 

spasm in, 13 

Sydenham's, of hands, 44 
35 



Choreiform movements, 508 
Circulation, portal, obstruction of, 

363 
Cirrhosis of liver, 387 

of liver, abdominal veins in, 
363 

of liver, spleen in, 412, 413 

of liver, toxaemia in, distin- 
guished from uraemia, 518 

of lung, 83, 315, 324 
Claudication, intermittent, 456 
Clavicles, prominence of, 63, 65 
Claw-hand, 46 

in chronic poliomyelitis, 46 

in paralysis of interossei and 
lumbricales, 46 

in progressive muscular atrophy, 
46 

in syringomyelia, 46 
Cleft palate, 20 
Club-foot, varieties of, 460 
Cog-wheel breathing, 156 
Cold sore, 18, 19, 517 

tremor of hands in, 43 
Colic, biliary, 417 

in gall-stone impaction, 393 

in plumbism, 394 

intestinal, 418 

renal, 393, 417 
Collapsed states, depressed fontanels 

in, 7 
Colon, fluid in, palpation of, 366 

inflation of, in diagnosis of ab- 
dominal tumors, 368, 370 
Coma, 517 

causes of, 517 

determination of hemiplegia in, 
518 

dilatation of pupil in, 15 

knee-jerk in, 512 

sphincteric reflexes in, 515 



546 



INDEX. 



Compensation, cardiac, establishment 

and failure of, 202-205 
Compression, coma in, symptoms in, 
519 
of lungs, 66 
Concussion, coma in, 519 
Congenital heart disease, 265 

spastic paralysis, gait in, 506 
Congestion, hypostatic, 360 
Conjunctivitis, 14 

distinguished from iritis, 14 
from overdose of arsenic, 14 
from overdose of iodide of pot- 
ash, 14 
with hay-fever, 14 
with influenza, 14 
with measles, 14 
with yellow fever, 14 
Consciousness, loss of, 517 
Constipation in local peritonitis, 
371 
tongue in, 22 
Contagion, psychic, choreiform move- 
ments in, 45 
Contractures following atrophic ar- 
thritis, 497 
hemiplegic, hand in, 46 
of arm, 37 

of the interossei and lumbricales, 
claw-hand in, 46 
Cord, compression of, anaesthesia in, 
510 
lesions of, knee-jerks in, 513 
paralysis, 506 

paralysis of, disorders of bladder 
and rectum in, 507 
Cornea, 16 
Costal angle, 64 
Cough, 165, 306 
Cramp, spasm in, 508 
Cranial-nerve paralysis, 506 



Cranium, 5 

size and shape, 5 
Cremasteric reflex, 514 
Crepitus in monarticular atrophic 
arthritis, 497 

in perigastritis, 369 

in perihepatitis, 369 

in perisplenitis, 369 

in peritonitis, 369 

peritoneal, 369 
Cretinism, 10 

deformed legs in, 10 

delayed closure of fontanels in, 6 

face in, 10 

lips in, 18-20 

mouth in, 18-20 

pot-belly in, 10 

teeth in, 20 

tongue in, 24 
Croup, 76 

Curvature of spine, 66, 70, 71 
Cyanosis, 92, 265 

of nails, 52 
Cyst, branchial, 33, 34 

dermoid, of back, 55 

of ovary, 449, 450 
Cystitis, symptoms in, 423 

urine in, 423, 435, 439 

with frequent micturition, 439 
Cystocele, 446 
Cystoscopy, 440 
Cyto-diagnosis, 353-356 

of pleural effusion, 354 

technique of, 354 

Debility, fibrillary twitching in, 508 

spleen in, 413 
Deformities, congenital, of heart, 265 

of chest, 62-73 

of hands, 46 
Degeneration, reaction of, 515 



INDEX. 



547 



Dementia paralytica, degeneration of 
handwriting in, 516 

paralytica, reaction of pupil in, 
15 

paralytica, sexual power in, 515 

paralytica, sphincteric reflexes 
in, 515 

paralytica, tongue in, 22 
Dermatitis, resulting from pediculi, 8 
Dextrocardia, 84 
Diabetes, acetonemia in, 428 

breath in, 21 

bronzed, 396 

coma in, signs in, 519 

dyspnoea in, 72 

malnutrition in, 2 

mellitus, 427 

mellitus, gangrene of toe in, 463 

optic neuritis in, 16 

retinal hemorrhage in, 16 

ulcer of toe in, 463 
Diaphragm, 69 

movements of, 69, 74, 76 

paralysis of, 71 
Diarrhoea, causes of, 399 

depressed fontanels in, 6 

malnutrition in chronic, 2 
Diastolic murmur (see Murmur) 

shock, 282 
Dibothriocephalus latus, 405, 409 
DietPs crisis, 418 
Digestion, painful, with hyperacidity, 

383 
Dilatation, cardiac, 205, 208, 291 
Diphtheria, larynx in, 26 

neuritis due to, 456 

tonsils in, 26 

with enlarged glands, 30 

with nasal discharge, 17 
Displacement of cardiac impulse, 82 
(see also Cardiac) 



Distention, flatulent, 398 
Distentions following atrophic ar- 
thritis, 497 
Dropsy, evident, 1 

in cardiac disease, 1 

in renal disease, 1 

increase of weight in, 1 

latent, 1 
Ductus arteriosus, persistence of, 

266 
Dulness on percussion, 130 
Dupuytren's contraction, 51 
Dysentery, arthritis in, 493 

chronic, anaemia in, 476 
Dyspepsia, malnutrition in chronic, 2 

statistics of, 382 
Dyspnoea, 71, 74, 521 (see also Breath- 
ing) 

causes of, 72 

nose in, 17 

mouth in, 18 

varieties of, 72 
Dystrophy, muscular lordosis in, 54 

Ear, gouty tophi of, 503 
Egophony, 169, 299, 346 
Electrical reactions, 515 
Emaciation, 2, 372, 392 
Emphysema, 60, 67, 317-322 

atrophic (or small-lunged), 317 

barrel chest in, 60, 67, 318 

breath sounds in, 319 

complementary, 321 

complications of, 320 

diagnosis of, 319 

interstitial, 321 

large-lunged, 317 

neck in, 29 

percussion signs in, 318 

radioscopy in, 533 

senile, 317 



548 



INDEX. 



Emphysema, subcutaneous, 321 (see 
Interstitial) 

with asthma, 320 

with bronchitis, 320 

with kyphosis, 54 

with tuberculosis, 315 
Empyema, 346, 350-351, 352 

necessitatis, 69, 290, 350 

with hypertrophic osteoarthri- 
tis, 40, 47 
Endocarditis, acute, 213, 251, 525 

chronic, 213-258 

in acute infectious arthritis, 495 
Endometritis, 448 
Eosinophile cells in blood, 471 
Eosinophilia, 479 
Epididymitis, 444 
Epigastric pain, 374 

pulsations, 85, 276 

reflexes, 514 

retraction, 84 

tumor, 375, 382 
Epigastrium, hernia in, 375 

inspection and palpation of, 374 

tumor of, 375 
Epilepsy, local paresthesia in, 510 

scars on forehead in, 8 

spasms in, 508 
Epiphyses, enlarged, in rickets, 461 
Epiphysitis, acute septic, 453 

acute septic, diagnosis from ar- 
thritis, 484 

chronic tuberculous, 454 
Epispadias, 443 
Epithelioma of ankle, 461 

of back, 55 

of hip, 19 

of nose, 17 

of thigh, 455 
Epulis, 25 
Equinus, 460 



Eruptions on forehead, 8, 9 
Erysipelas, cedema of eyelids in, 14 

symptoms of, 14 
Erythromelalgia, 462 
Ewald's test meal, 379 
Exophthalmic goitre, 11, 12, 31 

goitre, glucosuria in, 427 
Exostosis of thigh, 454 
Eyelashes in phthisis, 12 
Eyelids, dropping of, 16 

cedema of, 13, 14 
Eyes, 13, 14 

in Graves' disease, 11, 12 

in hydrocephalus, 5 

in jaundice, 14 

in muscle paralysis, 506 

in phthisis, 12 

Face, 5, 9 

after vomiting, 12 

in acromegalia, 8, 9 

in adenoids, 10, 11 

in alcoholism, 12 

in chronic diffuse nephritis, 12 

in cretinism, 10 

in exophthalmic goitre, 11, 12 

in general peritonitis, 12, 372 

in Graves' disease, 11, 12 

in heart disease, 12 

in intestinal obstruction, 12 

in leprosy, 11, 12 

in myxcedema, 10 

in nephritis, 12 

in paralysis agitans, 11 

movements of, 13 

cedematous, 12 

spasms of, 13 
Fallopian tubes, 448 
Faradic reaction in disease, 516 
Fat, distribution of, in alcoholism, 
12 



INDEX. 



549 



Fatigue, degeneration of handwriting 

in, 516 
Fatty metamorphosis of heart, 260 
Febrile disease, bulging fontanels in, 6 
Feces, abnormal ingredients in, 403 

bacteria in, method of examina- 
tion for, 404 

blood in, 403, 404 

color of, 402 

examination of, 402 

gall-stones in, 404 

microscopic examination of, tech- 
nique, 408 

mucus in, 403 

odor of, 403 

parasites in, eggs, diagnosis of, 
406, 407 

parasites in, types of, 404 

pus in, 404 

tissue shreds in, 404 

weight of, 402 
Feet, hot, in myocarditis, in arterio- 
sclerosis, 462 

in acromegalia, 47 
Fermentation in cancer of stomach, 

382 
Fever, continued, 3 

crisis in, 3 

determination of, 3 

dilatation of pupils in, 15 

emaciation in, 2 

in atropinism, 3 

infectious, 3 

infectious, giucosuria in, 427 

in inflammations, 3 

in nervous excitement, 3 

in pneumonia, 3 

in "septic" conditions, 3 

in sunstroke, 3 

intermittent, 3 

in toxic states, 3 



Fever, in tuberculosis, 3 

in typhoid, 3 

lysis in, 3 

nosebleed in, 17 

peritonitis, 371 

tremor of hands in, 43 

types of, 3 
Fibrillary twitching, 508 
Filariasis, blood in, 479 

parasites in, 483, 484 
Fingers, clubbed, 47-49 

in heart disease, 47-49 

in lung disease, 47-49 

in pleural disease, 47-49 
Fistulse, branchial, congenital, 34 
Fixation of costo-vertebral joints, 74 
Flat-foot, 460, 461 
Flattening of one chest, 66 
Flipper-hand in atrophic arthritis, 

46, 47 
Fluid, free, in abdomen, tests for, 369 

free, in ascites, 369 

free, in hsemoperitoneum, 369 

free, in peritonitis, 369 

free, in ruptured cyst, 369 
Fluoroscope, use of, 527 
Flush in phthisis, 12 
Follicular tonsillitis, 27 
Fontanels, 6 

bulging of, 6 

delayed closure of, 6 

depression of, 6 

time of closing of, 6 
Forehead, 8 

bony nodes of, 8, 9 

eruptions of, 8, 9 

eruptions of, differential diagno- 
sis in, 9 

scars of, 8 
Fremitus, tactile, 98 

tactile, in emphysema, 318 



550 



INDEX. 



Fremitus, tactile, in pleural thicken- 
ing, 349 
tactile, in pleuritic effusion, 348 
tactile, in pneumonia, 297 
tactile, in pneumothorax, 331 
tactile, in pulmonary tuberculo- 
sis, 308, 311 
vocal, 167-169 (see also Vocal) 

Friction, pericardial, 100, 268 
peritoneal, 369 
pleural, 100, 165, 337 

Frontal bone syphilis, 8, 9 

Funnel breast, 62 

Gait, ataxic, 506 

in paralysis agitans, 506 

in toe-drop, 506 

spastic, 506 
Gall-bladder, 393 

adhesions about, 395 

and bile-ducts, statistics on, 385 

enlarged, 395 

enlargement of, 394 

enlargement of, causes, 394 
Gall-duct, common, obstruction of, by 
stones, 392 

stones, 394 
Gall-ducts, 393 
Gall-stone in intestinal obstruction, 

395 
Gall-stones, 391 

in feces, 404 
Galvanic reaction in disease, 516 
Ganglion, 41 
GaDgrene, causes of, 463 

local, in Raynaud's disease, 49 

of buccal cavity, 26 

of lung, 357 

of lung, breath in, 21 

Raynaud's form of, 517 

toe in, 463 



Gas, poisoning by, coma in, 520 
Gastric cancer, tumor in, diagnosis of, 

375 
contents, tests of, 380 
dilatation, 383 

dilatation, malnutrition in, 2 
diseases, incidence and diagnosis 

of, 382 
fermentation, breath in, 22 
fermentation, tongue in, 22 
hemorrhage, with ulcer, 383 
peristalsis, 375 

peristalsis in adhesions of py- 
lorus, 375 
peristalsis in cancer of pylorus, 

375 
peristalsis in cicatrix of pylorus, 

375 
peristalsis in muscular spasm of 

pylorus, 375 
peristalsis in simple thickening 

of pylorus, 375 
stasis in disease, 384 
stasis, subjective symptoms in, 

384 
ulcer, 383 

ulcer, malnutrition in, 2 
ulcer, tongue in, 22 
ulcer, vomitus with bright blood 

in, 383 
General peritonitis, face in, 12 
Genitals, female, 445 

female, diseases of, blood in, 479 
female, inspection of, 446 
female, lesions of, 446 
female, methods of examination, 

445 
female, palpation of, 446 
male, 442 
German measles, glands in, 30 
Glands (see also Adenitis) 






INDEX. 



551 



Glands, cervical, 30 

cervical, in malignant disease, 30 

cervical, in tuberculosis, 30 

enlarged, in mesentery, 373 

in cankers, 30 

in caries of the teeth, 30 

in diphtheria, 30 

in German measles, 30 

in Hodgkin's disease, 30 

in lymphatic leukaemia, 30 

in the exanthemata, 30 

in tonsillitis, 30 

inguinal, enlarged when, 452 

of neck in syphilis, 30 
Glottis, obstruction of, 73, 76 
Glucosuria and its significance, 426 

experimental, 427 

transient, 427 
Goitre, simple, 31, 32 

with exophthalmus, 11, 12, 31 
Gonorrhoea, arthritis in, 493 

balanitis in, 443 

distended bladder in spasm of 
urethra in, 438 

inguinal glands in, 452 

orchitis in, 444 

with epididymitis, 444 

with frequent micturition, 439 
Gout, arthritis in, 501 

toe in, 463 

tophi, diagnosis of, 503 

tophi in tendon in, 40 

tophi in, test for, 488 
Gouty arthritis, 501, 503 

arthritis, destruction of bone in, 
503 

arthritis, x-ray of hand in, 504 
Graves' disease, 11, 12, 31 

disease, eyes in, 11, 12 

disease, face in, 11, 12 

disease, hands in, 42 



Graves' disease, tremor of hands in, 

44 
Groin, 452 

glands in, 452 

hernia of, 453 

hydrocele of cord in, 453 

psoas abscess in, 453 
Gumboil, 25 
Gums, 24 

hemorrhage of, 25 

in debilitated states, 25 

in lead-poisoning, 24 

in poisoning by mercury, 25 

in poisoning by potassic iodide, 
25 

in scurvy, 25 

lead line in, 24 

sordes of, 25 

spongy, 25 

suppuration of, 25 
Giinzburg's reagent, 380 

H^emadynamometer, Oliver's, 116 
Hsematemesis, in portal obstruction, 

390 
Hematocele, 445 
Hematoma, infected, of belly-wall, 

367 
Hematuria, causes of, 422 
Hsemin test, 379 
Haemoglobin, tests for, 464-466 
Hsemopericardium, 272 
Haemophilia, nosebleed in, 17 
Hemophilic arthritis, 503 
Hemorrhage, pulmonary, 305 
Hair, 7 

general loss of, 7 

in acute fevers, 7 

in myxcedema, 8, 10 

in phthisis, 12 

in syphilis, 7 



552 



INDEX. 



Hair, nits in, 8 

normal loss of, 7 

pediculi in, 8 

rubbing off of head in rickets, 7 
Hand in acromegalia, 47 
Hands, choreiform movements of, 44 

deformities of, 46 

evidence of occupation, 41 

examination of, 42 

in atrophic arthritis, 46, 47 

in chronic poliomyelitis, 46 

in contractures following hemi- 
plegia, 46 

in Graves' disease, 42 

in myxcedema, 46-48 

in paralysis of median or ulnar 
nerves, 46 

in progressive muscular atrophy, 
46 

in syringomyelia, 46 

moisture of, 42 

movements of, 42 

professional spasm of, 44 

spasms of, 44 

temperature of, 42 

tremor of, 43 

tremor of, causes, 43 

tremor of, in alcoholism, 44 

tremor of, in cold, 43 

tremor of, in fever, 43 

tremor of, in Graves' disease, 44 

tremor of, in hysteria, 44 

tremor of, in multiple sclerosis, 
44 

tremor of, in nervousness, 43 

tremor of, in old age, 43 

tremor of, in paralysis agitans, 
44 

tremor of, in toxaemia, 43 

tremor of, test for, 43 
Handwriting, degeneration of, 516 



Hang-nails, 52 

Hare-lip, 20 

Harrison's groove, 62 

Hay fever with conjunctivitis, 14 

Head, 5 

abnormalities of, 5 

in hydrocephalus, 5 

in idiocy, 5 

in rickets, 6 

movements of, 13 

open areas, 5 

shaking of, 13 

shaking of, in alcoholics, 13 

shaking of, in morphinism, 13 

shaking of, in poisoning by to- 
bacco, 13 

shaking of, in toxic conditions, 13 

sweating of, 7 
Heart, 171-267 

action of, 203, 257, 261-265 

apex, position, 97 

apex, impulse, 79, 82, 96 

apex, retraction, 84 

area, changes in, 132 

area, in pericarditis, 272 

area, normal, 129 

arrhythmia of, 263 

auscultation of, 171 

bradycardia, 262 

congenital malformations of. 265 

dilatation of, 208-210, 231 

diseases of, 199-267 

enlargement of (see Hypertrophy) 

examination of, 171-199 

fatty metamorphosis, 260 

hypertrophy of, 203, 205-208, 
210, 231, 243, 277 

hypertrophy, causes of, 205 

impulse, 79, 82 

impulse, absence of, 274 

impulse, displacement of, 82 



INDEX. 



553 



Heart impulse, modification of, 96 
in aortic regurgitation, 229-239 
in aortic stenosis, 239-246 
in mitral regurgitation, 210-220 
in mitral stenosis, 220-229 
in myocarditis (acute), 257 
in neuroses of (chronic), 258 
in pericarditis, 268, 274, 276 
in pleural adhesions, 83, 349 
in pleural effusion, 343 
in pneumothorax, 331 
in pulmonary regurgitation, 251 
in pulmonary stenosis, 252, 265 
inspection of, 79-86 
irregular action of, 263 

(see also A rrhythmia) 
lips in disease of, 18 
murmurs, 184—199 (see also 

Murmurs) 
outlines of, 128 
palpation of, 96 
palpitation of, 264 (see also 

Arrhythmia) 
parietal diseases of, 257-261 
percussion of, 129 
rapidity of (see Tachycardia) 
situs inversus, 345 
slow (see Bradycardia) 
sounds, accentuation of, 178, 179 
sounds, abnormalities of, 172 
sounds, character of, 172 
sounds, doubling of, 176, 181 
sounds, intensification of, 175, 

178-179 
sounds, metallic, 174, 182 
sounds, modifications of, 174 
sounds, muffling of, 182 
sounds, normal, 172 
sounds, position of, 171 
sounds, qualities of, 173 
sounds, reduplication of, 176, 181 



Heart sounds, rhythm of, 181 

sounds, shortening of, 209 

sounds, weakening of, 175, 179 

tachycardia, 261 

temperature, 3 

tricuspid regurgitation, 246 

tricuspid stenosis, 250 

uncompensated, 3 

valves, position of, 171 

valvular lesions, combined, 253 

valvular lesions of, 199 

weakness, 258 

(See also Cardiac) 
Heberden's nodes, 47, 50, 498 
Hemianesthesia, 510 
Hemiplegia, 506 

athetosis in, 45 

atrophy of disuse in, 37 

changes of nails in, 52 

determination of, in comatose 
state, 518 

paralysis of leg in, 456 

tongue in, 22 
Hemiplegic hand, following contrac- 
tures, 46 
Hemorrhage, anaemia in, 476 

bulging fontanels in, 6 

in retina, 16 

tendency of, in jaundice, 391 
Hemorrhoids, 441 
Hepatic abscess, symptoms in, 392 
Hernia, epigastric, 367, 375 

of groin, 453 

of scrotum, 445 

umbilical, 367 
Herpes labialis, 18, 19, 517 

tongue with, 22 

zoster, 517 
Herpetic stomatitis, 19 
Hip-joint, hypertrophic arthritis of, 
498 



554 



INDEX. 



Hip-joint, limitation of motion in, 
492 

Hodgkin's disease, glands in, 30, 373 
disease, inguinal glands in, 453 
disease, oedema of arm in, 38 
disease, spleen in, 412, 414 

Housemaid's knee, diagnosis of, 458 

Hydatid disease, blood in, 479 

Hydrocele, 444 

Hydrocephalus, 5 

bulging of fontanels in, 6 
delayed closure of fontanels in, 6 

Hydrochloric acid, absence of, in can- 
cer of stomach, 382 

Hydronephrosis, 415 

Hydropericardium, 272 

Hydrothorax, 330 

Hymen, imperforate, 446 

Hyperacidity, gastric, 383 
painful digestion in, 383 

Hyperesthesia, tests of, 510 

Hyperchlorhydria (see Hyperacidity), 
pain in, 393 

Hypertrophic arthritis, features of, 
498 
arthritis, hip-joint in, 498 
arthritis, kyphosis in, 54 
arthritis, limitation of motion in, 

501, 502 
arthritis, nerve pain in, 501 
arthritis, psoas spasm in, 493 
arthritis, signs in, 498 
arthritis, spine in, 499, 500, 501, 
502 

Hypertrophy, cardiac, 203, 205, 208, 
210, 231, 233, 277 
of lung, 67 

Hypoacidity, stomach trouble, 383 

Hypochlorhydria (see Hypoacidity) 

Hypospadias, 443 

Hypostatic congestion, 360 



Hysteria, anaesthesia in, 510 
atrophy in, 37 

choreiform movements in, 45 
coma in, 519 
hemianesthesia in, 510 
hyperesthesia in, 510 
paralysis in, 36, 456, 506 
ptosis in, 16 
spasm in, 13 
tremor of hands in, 44 

Idiocy, mouth in, 18 
Impulse, cardiac (see Cardiac) 
Incidence of diseases of the bladder, 
437 

of diseases of the intestine, 397 

of diseases of the kidney, 414 

of diseases of the liver, 384 

of diseases of the pancreas, 396 

of diseases of the stomach, 382 
Indicanuria, 397 
Infancy, examination of chest in, 520 

jaundice in, 15 
Infantile atrophy, malnutrition in, 2 
Infections, acute, arthritis in, 493 

acute, chills in, 3 

arthritis in, 492 

crippled joints in, 495 

fever in, 3 

leucocytosis in, 478 
Inflammation, oedema of arm in, 38 
Influenza, arthritis in, 493 

with conjunctivitis, 14 

with nasal discharge, 17 
Insomnia, 2 

emaciation due to, 2 

in painful diseases, 2 
Inspection of abnormal thoracic pul- 
sations, 82-87 

of apex beat, 79 

of cardiac movements, 79 



INDEX. 



555 



Inspection of deformities of chest, 62 
of peripheral vessels, 87 
of respiratory movements, 69 
of skin and mucous membranes, 

92 
of thorax, 60, 96 
Intestinal colic, 418 

contents, examination of, 402 
obstruction, acute and chronic, 

401 
obstruction, by gall-stone, 395 
obstruction, causes of, 401, 402 
obstruction, chronic, visible peri- 
stalsis in, 401 
obstruction, face in, 12 
obstruction, physical signs in, 401 
obstruction, symptoms in, 401 
parasites, 404 
tenderness, 398 
tenesmus, 398 
Intestines, cancer of, signs and symp- 
toms of, 402 
diseases of, constitutional mani- 
festations, 398 
diseases of, data for diagnosis, 

397 
diseases of, statistics on, 397 
gaseous distention in, and its sig- 
nificance, 398 
pain, 398 

parasites in, eggs, diagnosis of, 
406, 407 
Iritis, with irregular outline of pupil, 

15 
Ischio-rectal abscess, 441 

Jacksonian epilepsy, 44 

epilepsy, spasms of hand, causes 
of, 44 
Jaundice, 14, 93, 390 

catarrhal, 391 



Jaundice, causes of, 14, 390 

congenital, 392 

diagnosis of cause, 391 

in acute yellow atrophy, 392 

in biliary cirrhosis, 391 

in cancerous obstruction of gall- 
duct, 394, 395 

in cholelithiasis, 391 

in new-born, 391 

in portal cirrhosis, 391 

in syphilis, 391 

in toxaemia, 390 

in urine. 391 

in Weil's disease, 392 

itching in, 14 

malignant, 391 

mental depression in, 14 

of eye, distinguished from sub- 
conjunctival fat, 14 

of malaria, 15 

of mucous membrane, 14 

of new-born, 15 

of pernicious anaemia, 15 

of sepsis, 15 

of skin, 14 

results of, on body, 391 

secondary, in septicaemia, 392 

slow pulse in, 14 

stools in, 391 

with bile in urine, 14 

with bile-stained sweat, 14 

with catarrh of bile-ducts, 14 

with hepatic cirrhosis, 15 

with obstruction by stone, 15 

with syphilis, 15 

with toxaemia, 15 

with tumors obstructing bile- 
ducts, 15 
Jaw in acromegalia, 10 
Jaw-jerk, test for, 514 
Joints, ankylosis of, 491 



556 



INDEX. 



Joints, arthritis of, 492 

arthritis of, order of frequency 

in, 492 
bony outgrowths, 488 
capsular thickening and adhe- 
sions of, motion in, 490 
chronic diseases of, knee-jerks in, 

513 
creaking in, 491 
crepitus in, 491 
diseases of, 491 
diseases of, general spasm in, 

488, 489 
diseases of, psoas-spasm in, 488 
diseases of, shortening of limb in, 

491 
diseases of, symptoms of, 487 
enlargement of, 487 
examination of, 486 
excessive motion in, 491 
exudates in, 488 
fluctuation in, 487 
free bodies in, 491 
hip, hypertrophic arthritis of, 

498 
in atrophic arthritis, 497 
in hemophilic arthritis, 503 
in rheumatoid arthritis, 497 
inspection of, 486 
irregularities of contour, 488 
lesions of, relative frequency in, 

504 
lesions of, statistics on, 504 
limitations of motion, tests of, 

489 
muscular spasm, tests for, 489 
palpation of, 486 
radioscopy, 487 
sacro-iliac, hypertrophic arthritis 

of, 53 
sacro-iliac, tuberculosis of, 53 



Joints, spindle, in atrophic arthritis, 
47 
symmetrical involvement of, in 

arthritis, 497 
to distinguish muscular spasm 
from bony outgrowth, 490 

Keratitis, syphilitic, 16 

Kernig's sign, test for, 513 

Kidney, 414 

abscess of, 416 
abscess of, etiology, 417 
abscess of, signs of, 417 
contracted, urine in, 436 
cyst of, 415, 416 
cyst of, distinguished from hy- 
dronephrosis, 416 
diseases of, 415 
diseases of, evidence of, 414 
diseases of, pain in, 418 
diseases of, urine in, 418, 423, 

426 
floating, 417 
floating, pain in, 393 
floating, tenderness in, 415 
malignant disease of, 415 
movable, 417 
palpation of, 366, 417 
statistics on, 414 
tumors, characteristics of, 415 
tumors of, 415 

tumors of, method of examina- 
tion, 415 
tumors of, urine in, 423 

Knee, 458 

housemaid's, diagnosis of, 458 
tuberculosis of, distinguished 
from sarcoma, 455 

Knee-jerk, absence of, 511 

Knee-jerks, increased, differential di- 
agnosis in, 512 



INDEX. 



557 



Knee-jerks, in paralysis, 518 

test for, 511 
Knock-knee, 458 
Koplik's spots in measles, 25 
Kyphosis, 54 

in emphysema, 54 

in hypertrophic arthritis, 54 

in Paget's disease, 54 

in Pott's disease, 54 

in rickets, 54 

Lamblia intestinalis, 405 

Lavage, of stomach, method, 379 

Lead-colic, pain in, 394 

Lead-line, 24 

Lead-poisoning, paralysis in, 36, 37 
respiratory movements of belly 
in, 364 

Legs, bowed, 458 

chronic ulcers of, 458 
in cretinism, 10 
in hysteria, 457 
in multiple sclerosis, 457 
in spastic paraplegia, 457 
in tabes dorsalis, 457 
oedema of, causes of, 459 
osteomyelitis in, 459 
paralysis of, causes, 456 
paralysis of, differential diagno- 
sis in, 457 
sarcoma of, 459 
tenderness of, in neuritis, 459 
tenderness of, in trichiniasis, 459 
varicose veins of, 458 

Leprosy, 11 
face in, 11 
hand in, 50 
skin in, 11 

Leucocyte-count in general peritoni- 
tis, 372 

Leucocytosis, diagnostic value of, 478 



Leucocytosis, in appendicitis, 400 

in local peritonitis, 371 

in osteomyelitis, acute, 454 

occurrence of, 478 
Leukaemia, inguinal glands in, 453 

liver in, 389 

lymphatic, blood in, 479, 481 

myelogenous, blood in, 479, 480 

myelogenous, x-ray in, 480 

nosebleed in, 17 

spleen in, 412, 413 

tonsils in, 28 
Leukoplakia buccalis, 23 
Linese albicantes, 363 
Lipoma of arm, 38 
Lipomata of back, 55 
Lips, 18 

angioneurotic oedema of, 19, 20 

cancer of, glands in, 30 

chancre of, 19 

color of, 18 

epithelioma of, 19 

in cretinism, 18-20 

in heart disease, 18 

in lung diseases, 18 

in methemoglobinemia, 18 

in myxcedema, 20 

in poisoning by acetanilid, 18* 

in poisoning by coal-tar anti- 
pyretics, 18 
Litmus-test, 424 
Litten's sign, 76, 78, 306 
Liver, abscess of, distinguished from 
syphilis or malignant disease, 
388 

abscess of, symptoms in, 388 

acute yellow atrophy of, 389 

amyloid, disease of, 388 

atrophy of, 389 

cancer of, 387 

cancer of, diagnosis of, 388 



558 



INDEX. 



Liver, cancer of, emaciation in, 388 
cirrhosis of, 387 
cirrhosis of, abdominal veins in, 

363 
cirrhosis of, anaemia in, 476 
cirrhosis of, atrophic, 389 
cirrhosis of, emaciation in, 2 
cirrhosis of, latent, 387 
cirrhosis of, portal obstruction in, 

387 
cirrhosis of, uncompensated, 387 
congestion of, 387 
diseases of, 385 
diseases of, cerebral symptoms 

in, 393 
diseases of, signs in, 385 
enlargement, 386 
enlargement, causes of, 387 
enlargement, conditions with 

which confounded, 386 
enlargement, diagnosis of, 386 
enlargement, in obstructive jaun- 
dice, 388 
fatty, 387 

growth of, in cancer, 388 
hydatid disease of, 389 
in leukaemia, 389 
malignant disease of, symptoms 

in, 392 
pain and tenderness in, 385 
palpable normally, 366 
portal obstruction in, 389 
statistics on, 384 
syphilis of, 388 
syphilis of, distinguished from 

cirrhosis or malignant disease, 

388 
tumors of, 375 
Locomotor ataxia, atrophic arthritis 

in, 497 
Lordosis, 54 



Lordosis in muscular dystrophy, 54 
in tuberculosis, 54 
with abdominal tumors, 54 
with pregnancy, 54 

Lumbago, 53 

Lung, abscess of, 21, 35J 

acute miliary tuberculosis of, 316 

adventitious sounds (see Rtiles) 

anatomy of, 57 

atelectasis of, 82, 163, 304, 359 

auscultation of, 149-165 

cancer of, 67, 358 

chronic interstitial pneumonia, 

83, 315, 324 
cirrhosis of, 324 
collapse of (see A telectasis) 
congestion of (see CEdema) 
consolidation of (see Solidifica- 
tion) 
diseases of, 292-329 
diseases of fingers in, 47, 49 
diseases of lips in, 18 
emphysema of, 317-321 
fibroid disease of, 83, 315, 324 
fistula sound, 170 
gangrene of, 21, 357 
hypertrophy of, 67, 321 
malignant disease of, 67, 358 
miliary tuberculosis of, 316 
cedema of, 360 
palpation of, 98 
percussion of, 131-136 
phthisis, 304-316 
pneumonia, 296, 302, 303, 360 
position of, 58 
radioscopy of, 532 
rales in disease of, 161, 306 
reflex, 136 
Rontgen ray examination of, 57, 

357 
sarcoma of, 30, 38, 358 



INDEX. 



559 



Lung, solidification of, 298, 311, 323 
sputa in diseases of, 324 
syphilis of, 323 
tuberculosis of, 304-316 
Lupus erythematosus, nose in, 17 
Lymphangiectasis, filarial, 453 
Lymphatic leukaemia, blood in, 479 

glands in, 30 
Lymphocyte cells, in blood, 471 

cells, in pleural fluid, 353 
Lymphocytosis, 479 
in debility, 479 

Malaria, anaemia in, 476 

chills in, 3 

jaundice of, 392 

parasites in, 482 

spleen in, 412 

with jaundice, 15 
Malignant disease, anaemia in, 476 
Malnutrition, 2 

emaciation in, 2 

in anorexia nervosa, 2 

in chronic diarrhoea, 2 

in chronic dyspepsia, 2 

in diabetes, 2 

in gastric cancer, 2 

in gastric dilatation, 2 

in gastric ulcer, 2 

in infantile atrophies, 2 

in oesophageal stricture, 2 
Massage, leucocytosis in, 478 
Mast cells, in blood, 471 
Measles, conjunctivitis in, 14 

Koplik's spots in, 25 

oedema of face in, 10, 14 
Mediastinal glands, tuberculosis of, 
524 

pressure, signs, 284, 521 

tumors, 38, 290 
Mediastinitis, 276, 278, 524 



Mediastinum, diseases of, 521, 525 
Megaloblasts, 470, 475, 477 
Melaena, 383 
Meningitis, bulging fontanels in, 6 

strabismus in, 16 

tuberculous, optic neuritis in, 16 
Mensuration, 56 

Mental symptoms in myxcedema, 10 
Meralgia paraesthetica, 455 
Mesenteric thrombosis, 373 
Mesentery, enlarged glands of, 373 
Metallic tinkle, 170, 232 
Metatarsalgia, 463 
Meteorism, respiratory movements of 

belly in, 364 
Methaemoglobinaemia, lips in, 18 

test of, 18 
Microcephalia, 5 
Migraine, aphasia in, 516 
Mind, depression of, in jaundice, 391 

in general peritonitis, 371 
Mitral disease, 210, 229 (see also 
Heart) 

regurgitation, 210 

stenosis, 220 
Monoplegia, 506 

leg in, 457 
Morbus coxae senilis, 498 
Morton's disease, 463 
Morvan's disease, 50 
Motion, disorders of, 505 
Mouth, canker-sores of, 19 

fissures in, 18 

herpes of, 18, 19 

in adenoids, 10-18 

in cretinism, 18-20 

in dyspnoea, 18 

in idiocy, 18 

mucous patches in, 18-25 

syphilitic ulcers of, 18 
Movements, respiratory, 69 



560 



INDEX. 



Mucous membrane ir jaundice, 14 

Mucus in feces, 403 

Multiple sclerosis, intestinal tremor 
of, 44 
sclerosis, knee-jerks in, 513 
sclerosis, nystagmus in, 16, 44 
sclerosis, paraplegia in, 457 
sclerosis, speech in, 44 
sclerosis, tremor in, 44 
sclerosis, with spastic gait, 44 

Mumps, 30 

" accidental," 194 
orchitis in, 444 

Murmurs, arterial, 198 
at apex, 212 
at xiphoid, 188 
cardiac, 184-198 
cardiorespiratory, 197 
conduction of, 188 
diagnostic interpretation of, 190, 

249 
diastolic, 187, 234-236 
diastolic, in anaemia, 196 
diastolic, in aneurism, 286 
diastolic, in aortic area, 286 
diastolic, in aortic regurgitation, 

234 
diastolic, in ensiform cartilage, 

234 
diastolic, in mitral area, 235 
diastolic, in mitral stenosis, 224 
diastolic, in pulmonary area, 251 
diastolic, in pulmonary regurgi- 
tation, 251 
disappearance of, 191, 225 
effects of exercise on, 193 
effects of position on, 193 
effects of respiration on, 193 
from pressure, 198 
functional, 194, 195, 196, 244 
hsemic (see Functional) 



Murmurs, in aortic aneurism, 285 
in aortic area, 235, 239, 240-246 
in aortic regurgitation, 235 
in aortic roughening, 219, 238, 

244 
in aortic stenosis, 240 
in back, 212 
in mitral area, 212, 218, 222, 

226 
in mitral regurgitation, 212, 218 
in mitral stenosis, 222-225 
in neck, 196, 198 
in pulmonary area, 196, 251, 252 
in pulmonary regurgitation, 251 
in pulmonary stenosis, 252 
in relative insufficiency, 239, 244 
in tricuspid area, 188, 247 
in tricuspid regurgitation, 247 
in tricuspid stenosis, 247 
length of, 193 
maximum intensity of, 190 
metamorphosis of, 194 
musical, 192 
of ansemia, 196, 244 
of Flint, 227, 239 
organic, 190, 196 
position of, 187 
presystolic, 187 
production of, 184 
quality of, 192 
significance of, 190 
systolic, at apex, 212 
systolic, at base, 240 
systolic, in tricuspid area, 188, 

247 
systolic, over arteries, 198 
terminology of, 184 
time of, 186 
transmission of, 188 
vascular, 198 
venous, 198 



INDEX. 



661 



Muscle, ilio-psoas, when palpable, 366 

sounds, 146, 295 
Muscular-dystrophy, lordosis in, 54 
Mydriasis, causes of, 15 
Myelitis, acute, bedsores in, 517 

sexual power in, 515 

transverse or diffuse, paraplegia 
in, 457 
Myocarditis, acute, 257 

chronic interstitial, 258 

diagnosis of, 259 

hot feet in, 462 

in acute rheumatism, 257 

physical signs in, 258 
Myoma of uterus, 448 
Myxcedema, 10 

changes of nails in, 52 

diagnosis by palpation, 10 

dry skin in, 10 

face in, 10 

hand in, 46-48 

increase of weight in, 1 

infantile form, 10 

infiltration with mucin in, 1 

lips in, 20 

loss of hair in, 8, 10 

mental dulness in, 10 

nose in, 17 

onset of symptoms in, 10 

puffiness of face in, 10 

subnormal temperature in, 10 

temperature in, 3 

tongue in, 24 

Nails, 52 

capillary pulse, 52 

changes, in chronic skin diseases, 

52 
changes, in hemiplegia, 52 
changes, in myxcedema, 52 
changes, in neuritis, 52 
36 



Nails, changes, in pulmonary osteo- 
arthropathy, 47-49 

changes, in syringomyelia, 52 

disturbed nutrition of, 52 

grooved, after acute disease, 52 

in anaemia, 52 

in cyanosis, 52 

incurvation of, 47, 49, 52 

indolent sores around, 52 
Navel, inflammation or thickening of, 

367 
Neck, 29 

abscess of, 29-31 

actinomycosis of, 34 

diseases of, 29-35 

in emphysema, 29 

in paralysis agitans, 1 1 

in phthisis, 29 

length of, 64 

pulsations in, 33, 34 

scars of, 29-31 
Necrosis, anaesthetic, in leprosy, 50 

of bone, in tuberculous arthritis, 
492 
Nephritis, acute, urine in, 435 

chronic diffuse, face in, 12 

chronic glomerulo-, anaemia in, 
476 

diagnosis of, 14 

face in, 12 

glomerular, chronic, urine in, 
435 

glomerular, polyuria in, 436 

oedema of arm in, 38 

oedema of eyelids in, 14 

optic neuritis in, 16 

parenchymatous, 435 

retinal hemorrhage in, 16 

symptoms, 423 

temperature in, 3 

urine in, 423 



562 



INDEX. 



Nephrolithiasis, symptoms in, 423 

urine in, 423 
Nervousness, tremor of hands in, 43 
Nervous system, 505 
Neuralgia, 75 

red, of extremities, 462 
Neurasthenia, fibrillary twitchings in, 
508 

knee-jerk in, 511 

with ptosis, 16 
Neuritis, anaesthesia in, 36 

atrophy of arm in, 37 

changes of nail in, 52 

due to pressure, 35 

hysterical, paralysis in, 36 

multiple, paralysis in, 37 

obstetrical, paralysis in, 36 

optic, 16 

pain in, 36 

paresthesia in, 36 

paralysis of leg in, 456 

postdiphtheritic, 29 

pressure, paralysis in, 35 

pressure, test for, 36 

tenderness of leg in, 459 

toxic, paralysis in, 36 

with partial paralysis of both 
legs, 457 
New-born, jaundice in, 391 
Nodes, bony, in syphilis, on leg, 459 

Heberden's, 47-50 

in hypertrophic arthritis, 498 

on forehead, 9 

syphilitic, 9-38 
Noma, 26 

Normoblasts in blood, 470, 475, 477 
Nose, 17 

epithelioma of, 17 

falling of bridge in, 17 

hemorrhage of mucous mem- 
brane in, 17 



Nose, in acne rosacea, 17 

in acromegalia, 10, 17 

in adenoids, 17 

in alcoholism, 12, 17 

in dyspnoea, 17 

in lupus erythematosus, 17 

in myxcedema, 17 

local diseases of, 17 

significance of dried blood in, 17 

size and shape, 17 

tuberculosis of, 17 
Nosebleed, 17 

in fever, 17 

in haemophilia, 17 

in leukaemia, 17 

in purpura, 17 

in trauma, 17 
Nutrition of chest 65 
Nystagmus, 16-44 

multiple sclerosis with, 16 

Obesity, 1 

Obstruction, laryngeal, 76 
Ocular motions, 16 
(Edema, 93, 217 

angioneurotic, 459 

diagnosis of cause, 38 

in anaemia, 459 

in deficient local circulation, 459 

in flat-foot, 459 

in hemiplegia, 459 

in inflammation, 459 

in nephritis, 459 

in neuritis, 459 

in obesity, 459 

in pressure, 459 

in thrombosis, 459 

in uncompensated heart lesions, 
459 

in varicose veins, 459 

of arm in mediastinal disease, 521 



INDEX. 



563 



(Edema of eyelids, 13, 14 

of lungs, 294, 360 
(Esophagus, stricture of, 2 
Oliguria, 419 

Omentum, tubercular deposits in, 375 
Opium-poisoning, coma in, 519 

shaking of head in, 13 
Optic atrophy, 16 

atrophy, as result of optic neuri- 
tis, 16 

neuritis, 16 
Orchitis, 444 
Osteitis deformans, 6, 456 

deformans, bony thickening in, 6 
Osteoarthritis, 499 

Osteo-arthropathy, pulmonary, hy- 
pertrophic, 40-43, 47 
Osteoma of thigh, 454 
Osteomyelitis, acute, leucocytosis in, 
454 

acute septic, 453 

acute septic, diagnosis from ar- 
thritis, 454 

chronic tuberculous, 454 

tibia in, 459 
Ovarian disease, diagnosis of, 450, 451 
Ovaries, 449 

abscess of, 449 

cyst of, 449, 450 

cyst of, with twisted pedicle, 450 

tumors of, 450 
Ovaritis, 449 
Oxaluria, 433 
Oxyuris vermicularis, 405 

Paget's disease, 6, 456 
disease, arm in, 40 
disease, bony thickening in, 6 
disease, enlargement of skull in, 6 
disease, with kyphosis, 54 

Pain, in cancer of stomach, 382 



Pain, in intestinal diseases, 398 

in kidney disease, 418 

in liver disease, 385 

in local peritonitis, 371 

in lumbago, 53 

in obstetrical neuritis, 36 

in osteomyelitis, 459 

in pressure neuritis, 35 

in syphilitic nodes of humerus, 38 

in toxic neuritis, 36 
Palate, paralysis of, absence or di- 
minished reflex in, 29 

soft, adhesions, 29 

soft, perforation of, 29 
Pallor, 93 

in phthisis, 12 
Palpation, 96-103 

and dipping, 369 

and friction, pleural or pericar- 
dial, 100 

in aneurism, 280-282 

in myxcedema, 10 

of abdomen, methods of, 364 

of apex-beat, 96 

of normal abdomen, 366 

of rales, 101 

of the pulse, 103-111 

of thrills, 97 

of voice vibrations, 98 

(see also Fremitus) 
Palpitation, 264 
Pancreas, 395 

cancer of, diagnosis of, 395 

cancer of, jaundice of, 394, 395 

cyst of, 396 

diseases of, 395 

diseases of, aids in diagnosis of, 
396 

diseases of, diabetes in, 396 

diseases of, diagnosis of, 395 

diseases of, stools in, 395 



564 



INDEX. 



Pancreas, diseases of, urine in, 395 

statistics on, 396 

tumor of, 375, 395 

tumor of gall-bladder in, 395 
Pancreatitis, acute, 396 
Paresthesia, 510 

in neuritis, 36 
Paralyses, cerebral, knee-jerk in, 512 
Paralysis, 506 

agitans, 11-13 

agitans, face in, 11 

agitans, gait in, 506 

agitans, hands in, 13 

agitans, rigidity of neck in, 11 

agitans, tremor of hands in, 44 

bulbar, 29 

congenital, choreiform move- 
ments in, 45 

in acute anterior poliomyelitis, 
36 

in anterior poliomyelitis, 456 

in chorea, 457 

in diseases of spinal cord, 37 

in hemiplegia, 456 

in hysteria, 36, 456, 457, 506 

in lead-poisoning, 36, 37 

in multiple neuritis, 37 

in multiple sclerosis, 457 

in neuritis, 456 

in obstetrical neuritis, 36 

in pressure neuritis, 36 

in tabes, 457 

in toxic neuritis, 36, 37 

in transverse myelitis, 457 

in traumatic neurosis, 36 

infantile cerebral, athetosis in, 45 

of brain, 506 

of cord, 506 

of cranial nerve, 506 

of interossei and lumbricales, 
claw-hand in, 46 



Paralysis of intestines, in general 
peritonitis, 371 

of leg, 456 

of median or ulnar nerves, claw- 
hand in, 46 

of palate, test for, 29 

of peripheral nerve, 506 

serratus, scapula in, 55 

with contraction of pupil, 15 
Paralytic thorax, 63 
Paraphimosis, 443 
Paraplegia, 457, 506 

spastic, 457 
Parasites, animal, diseases due to, 
blood in, 479 

in feces, 404 

in the blood, 482 

intestinal, anaemia in, 476 

intestinal, eggs of, 406, 407 
Paresis, 506 
Paronychia, 52 
Parotid gland, cancer of, 30 

gland, enlargement of, 30 
Parturition, leucocytosis in, 478 
Passive congestion, in liver enlarge- 
ment, 387 
Patella, floating of, test for, 488 
Pectus carinatum, 62 
Pediculi in hair, 8 
Penis, 443 

cancer of, 444 

chancre of, 443 

chancroid of, 443 

discharge from, 443 

inflammations of glands of, 443 

malformations of, 433 
Peptic ulcer, pain in, 393 
Percussion, auscultatory, 125 

force of, 122 

immediate, 118 

mediate, 119-136 



INDEX. 



565 



Percussion of abdomen, 369 

of lung borders, 133 

outlines of thoracic organs, 58, 
128 

palpatory, 136 

resonance, 127 

resonance, amphoric, 135 

resonance, cracked-pot, 134 

resonance, dull, 128 

resonance, flat, 128 

resonance, tympanitic, 130 

resonance, vesicular, 128 

technique of, 118 
Pericardial friction (see Pericarditis) 
Pericarditis, acute plastic, 268 

diagnosis of, 270, 275 

dry, 268 

fibrinous, 268 

friction, diagnosis of, 270 

friction in, 268 

with effusion, 271 

with effusion, diagnosis of, 275 
Pericardium, adherent, 276 

diseases of, 268-280 
Perinephritic abscess, 54, 416 

abscess, psoas spasm in, 493 
Perineum, ruptured, 446 
Periostitis, 459 

Peripheral nerve lesions, anaesthesia 
in, 510 

nerve lesions, hyperesthesia in, 
510 

nerve paralysis, 506 

neuritis, knee-jerk in, 512, 513 
Peristalsis, visible, gastric, 375 

visible, in intestinal obstruction, 
401 
Peritoneum, cancer of, anaemia in, 
372 

cancer of, ascites in, 372 

cancer of, emaciation in, 372 



Peritoneum, cancer of, signs in, 

372 
cancer of, tumors in, 372 
diseases of, 370 

tuberculosis of, anaemia in, 372 
tuberculosis of, ascites in, 372 
tuberculosis of, emaciation in, 

372 
tuberculosis of, signs in, 372 
Peritonitis, 370 
causes of, 371 
general, 371 

general, facial expression in, 372 
general, fever in, 371 
general, intestinal paralysis in, 

371 
general, leucocyte count in, 372 
general, mind in, 371 
general, pulse in, 371 
general, swollen belly in, 371 
general, tenderness in, 371 
general, vomiting in, 371 
local, albuminuria in, 371 
local, anorexia in, 371 
local, constipation in, 371 
local, fever in, 371 
local, leucocytosis in, 371 
local, muscular spasm in, 371 
local, pain in, 371 
local, symptoms in, 371 
local, tenderness in, 371 
local, tumor in, 371 
respiratory movements of belly 

in, 364 
with thickening or inflammation 

of navel, 367 
Peri-urethral abscess, 443 
Pernicious anaemia, blood in, 476 
anaemia, jaundice of, 392 
anaemia, remissions in, 477 
anaemia, with jaundice, 15 



566 



INDEX. 



Pharyngitis, general redness in, 26 

of smokers, 29 
Pharynx, 26 

abscess of, 28 

in diphtheria, 26 

in pharyngitis, 26 

in scarlet fever, 26 

method of examination, 26 
Phimosis, 443 
Phlebitis, 455 
Photophobia, 15 
Phthisis, 11, 304-316 

acute, 316 

advanced, 311 

chronic, 308-316 

dilatation of pupils in, 15 

eyelashes in, 12 

eyes in, 12 

fibroid, 66 

flush in, 12 

hair in, 12 

incipient, 304 

neck in, 29 

pallor in, 12 

pupils in, 12 

skin in, 11 

thoracic deformity in, 64 

with fatty liver, 387 

(see also Tuberculosis) 
Pigmentations in buccal cavity, 26 
"Pink-eye," 14 
Pin-worm, in feces, 405 
Platelets in blood, 472 
Pleura, cancer of, 353, 358 

diseases of, 330-356 
Pleural adhesions, 78 

cancer or hydatid of lung, 
353 

effusion, 70, 76, 338-348 

effusion, diagnosis from pleural 
thickening, 351 



Pleural effusion, diagnosis from pneu- 
monia, 360 

effusion, diagnosis from sub- 
diaphragmatic effusions, 352 

effusion, encapsulated, 349 

effusion, signs during absorption 
of, 348 

exudate, cells in, 354 

friction, 100, 165, 337 

friction, distinction from muscle 
sounds, 338 

friction, distinction from pericar- 
dial friction, 270 

friction, distinction from rales, 
338 

friction, means of eliciting, 166, 
167 

thickening, 349, 351 
Pleurisy, 330-348 

clubbed fingers with, 47, 49 

diaphragmatic, 337 

dry, 336 

egophony in, 169 

heart in. 343, 344 

pain in, 336 

plastic, 336 

pulsating, 87, 350 

radioscopy of, 533 

restrained breathing in, 75 

tuberculous, 354, 355 
Plumbism, blood in, 470 

gums in, 24 

paralysis in, 36, 37, 456 
Pneumococcus infection, arthritis in, 

493 
Pneumonia, 296-304 

aspiration, 302 

broncho-, 303 

catarrhal, 303 

central, 296, 531 

chronic interstitial, 324 



. 



INDEX. 



567 



Pneumonia, crepitant rales in, 299 

croupous (or lobar), 296 

croupous, blood in, 478 

croupous, diagnosis from pleur- 
isy, 302 

croupous, diagnosis of, 301 

croupous, egophony in, 299 

croupous, signs in, 296 

croupous, sputa in, 326, 328 

hypostatic, 360 

inhalation, 302 

lobular, 303 

massive, 296 

migratory, 300 

resolution of, 300 

tuberculous, 302, 304 
Pneumopyothorax, 332 
Pneumoserothorax, 332 
Pneumothorax, 67, 70, 330 
Poikilocytosis in blood smears, 470, 

475 
Poisoning by gas, coma in, 520 

by illuminating gas, breath in, 
22 

by mercury, gums in, 25 

by potassic iodide, gums in, 25 

lead, lead-line in, 24 

opium, coma in, 519 
Poisons, anaemia, in, 476 

glucosuria in, 427 
Poliomyelitis, anterior, 456 

atrophy in, 37 

chronic, claw-hand in, 46 
Polychromasia in blood smears, 470, 

475 
Polynuclear cells in blood, 471 
Polyuria, 419 
Portal obstruction, causes of, 390 

obstruction, signs of, 389 

stasis, ascites in, 372 
Postepileptic coma, 520 



Pott's disease, 66 

disease, cervical, symptoms of, 

33 
disease, cervical, with abscess, 31 
disease, diagnosis of, 493 
disease, vertebrse in, 33 
disease, with kyphosis, 54 
Pregnancy, choreiform movements in, 
45 
glucosuria in, 427 
lordosis in, 54 
spasm in, 13 
tubal, 449 
Pressure, arterial, 111-117 

arterial, methods of measuring, 

111 
diastolic, 108, 116 
mediastinal, 521 
systolic, 106, 114 
Presystolic murmur (see Murmur) 
Primary polyarticular artophic ar- 
thritis, diagnosis of, 497 
Procidentia, 447 

Progressive muscular atrophy, fibril- 
lary twitchings in, 508 
muscular atrophy, reaction of de- 
generation in, 516 
Prominence, local, 68 

of chest, 68 
Prostate, hypertrophy of, distended 

bladder in, 438, 439 
Prostatitis, acute, retention of urine 

in, 439 
Pseudo-leuksemia, tonsils in, 28 
Psoas abscess, 453, 455 

spasm in disease, 493 
Psychic functions, examinations of, 

517 
Ptosis, 16 

in hysteria, 16 

in neurasthemia, 16 



568 



INDEX. 



Ptosis in syphilis, 16 
Pulmonary disease, 292-329 (see 
Lung) 

hemorrhage, 305 

oedema, 294, 360 

osteoarthropathy, 41-43, 47 

regurgitation, 251 

stenosis, 252 

syphilis, 323 

tympanites, 321 
Pulmonic area, 171, 178, 196, 251, 252 

second sound, 178 
Pulsating pleurisy, 87 
Pulsation, abnormal, 82-87, 280 

capillary, 91, 232 

epigastric 85 

venous, 88, 247 

venous, in tricuspid disease, 247 

visible, 85 
Pulse, 103-117 

anacrotic, 107 

bounding, 107 

capillary, 52, 232 

compressibility of, 106 (see also 
Arterial pressure) 

Corrigan's, 233 

dicrotic, 107 

frequency of, 105, 261 

in aneurism, 104 

in aortic regurgitation, 233 

in aortic stenosis, 104, 242 

in peritonitis, 371 

irregularity of, 105, 263 

method of feeling, 104 

rate, 105 

rhythm or regularity, 105 

slow, 262, 391 (see Bradycardia) 

tension, 108 

value of, 103 

venous, 88 

volume, 106 



Pulse, water-hammer, 233 

wave, size and shape of, 106 

(see also Arterial vails) 

(see also Arterial pressure) 
Pupil, 15 

Argyll-Robertson, 15 

contraction of, 15 

dilatation of, 15 

irregularity of, 15 
Pupils, in phthisis, 12 

reflexes, 15, 511 

tests of reflexes of, 15 

with sluggish reaction, 15 
Purpura, nosebleed in, 17 
Pus in fseces, 404 

tube, 448 

tube, cause of peritonitis, 371 
Pylephebitis, 388 
Pyloric stenosis, in cancer of stomach, 

382 
Pylorus, stenosis of, gastric peristalsis 
in, 375 

stenosis of, peristalsis in, 364 
Pyonephrosis, 416 
Pyorrhcea alveolaris, 25 
Pyuria 421, 422 

Quinsy sore throat, 28 

Rachitis, effects on chest, 60-63 

epiphyses in, 40 

head in, 6 

teeth in, 20 

(see also Rickets) 
Radioscopy, 79, 287, 527-534 
Rales, 161-165 

bubbling, 161 

consonating, 309 

crackling, 162 

crepitant, 163, 299 

diagnosis of, 167 






INDEX. 



569 



Rales, "dry," 162 

"moist," 161 

musical, 164 

palpable, 101 

varieties of, 161 
Raynaud's disease, 49, 462 

disease, gangrene in, 49, 463 

disease, syncope in, 49, 517 
Reaction of degeneration, 515 
Recti, separations of, 367 
Rectum, abscess of, 441 

cancer of, 442 

fissure of, 441 

fistula of, 441 

hemorrhoids of, 441 

methods of examination, 441 

symptoms which suggest exami- 
nation, 440 
Reflex, lung, 136 
Reflexes, 510, 511 

deep, 513 

exaggerated pharyngeal, 29 

in bulbar paralysis, 29 

in postdiphtheritic neuritis, 29 

of pupil, 511 

superficial, 514 
Regurgitation, aortic, 234 

mitral, 212, 218 

pulmonary, 251 

tricuspid, 188, 247 
Renal calculus, 417 

calculus, symptoms, 423 

calculus, urine in, 423 

colic, 393, 417 

disease, ascites in, 372 

disease, diuresis in, 1 

disease, sweating in, 1 

disease, weight in, 1 
Resistance, sense of, 136 
Resonance (see Percussion resonance) 
Respiration (see Breathing) 



Respiratory movements, 69-71 

sounds, 151-161 (see Breathing) 

rhythm, 74 
Restriction of thoracic movements, 70 
Retina, 16 

hemorrhage of, 16 

hemorrhage of, in anaemia, 16 

hemorrhage of, in diabetes, 16 

hemorrhage of, in nephritis, 16 
Retraction of thorax, 70, 73 

causes of, 76 

causes, lung, 291, 315 
Retrocele, 446 

Rheumatoid arthritis, 493, 496 
Rickets, arm in, 40 

delayed closure of fontanels in, 6 

epiphyses in, 40, 461 

head in, 6 

rubbing off of hair of head in, 7 

spleen in, 412 

sweating of head in, 7 

teeth in, 20 

with kyphosis, 54 
Romberg's sign, 509 
Rosary, rachitic, 63 
Rose spots, diagnosis of, 363 
Round-worm in faeces, 405 

Sahli's test for haemoglobin, 465 
Salpingitis, 448 
Sarcoma of arm, 38, 39 

of belly wall, 367 

of femur, 454, 455 

of leg, 459 

of lung, oedema of arm in, 38 

of mediastinum, oedema of arm 
in, 38 

of scapula, 55 

of testis, 444 

of thyroid gland, 32 

of tonsil, 27 



570 



INDEX. 



Scapula, angel-wing, 55 

prominent, 55 

sarcoma of, 55 
Scar from syphilitic ulcers on leg, 

459 
Scarlet fever, pharynx in, 26 

fever, tonsils in, 26, 27, 28 
Scars of forehead, 8 

significance of, 31 
Scoliosis, with twisting of spine, 54 
Scrotum, 444 

hernia of, 445 

hydrocele of, 444 
Scurvy, gums in, 25 
Senility, tremor of hands in, 43 
Sensation, delayed, 510 

disorders of, 509 

dissociation, 510 
Sepsis with jaundice, 15 
Septicaemia with jaundice, 392 
Serratus paralysis, scapula in, 55 
Sexual power, 515 
Shock, diastolic, 282 
Sigmoid, cancer of, 402 
Skin, diseases of, chronic, blood in, 
479 

in jaundice, 14 

in leprosy, 11 

in myxcedema, 10 

in phthisis, 11 

itching of, in jaundice, 391 

lesions of, trophic, in atrophic ar- 
thritis, 497 
Skull, enlargement of, 6 
Sleep, loss of, 2 
Smallpox, eruptions on forehead in, 9 

throat in, 27 
Snuffles, syphilitic, 17 
Sordes, 25 

Sounds, cardiac, 171-179 (see also 
Heart) 



Sounds in lung fistula, 170 

respiratory, 151-161 (see also 
Breathing) 
Spade-hand, 46 
Spasm, muscular, 371, 488-490, 492 

psoas, 493 

tonic, 507, 508 
Spasms, clonic, 507, 508 

hands in, 44, 45, 46 

of face, 13 
Spastic paraplegia, knee-jerk in, 512 
Speech, loss of, 516 
Sphincteric reflexes, 515 
Sphygmograph, 533 
Sphygmometer, 111 (see Blood press- 
ure) 
Spina bifida, 55 

Spinal cord, pressure on, paraplegia 
in, 457 

cord, severing of, knee-jerk in, 
512 

curvature, 54, 66, 70 

curvature, scapula in, 55 
Spine, chronic diseases of, sphincteric 
reflexes in, 515 

in hypertrophic arthritis, 499, 
500, 501, 502 

normal flexibility of, 502 

tuberculosis of, 493 
Spleen, diseases of, 59, 410 

enlarged, distinguished from 
other tumors, 413 

enlargement of, 410, 412, 413 

palpation of, 410-412 

percussion of, 412 

in portal obstruction, 390 
Splenic anaemia, 412, 413 
Spondylitis deformans, 499 
Sputa, appearance of, 324 

examination of, 324-329 

odor of, 325 






INDEX. 



571 



Sputa, origin of, 324 

staining of, 326 
Squint, 16 

Starvation, breath in, 21 
Statistics on bladder, 437 

on gall-bladder and bile-ducts, 
385 

on diseases of liver, 397 

on joint lesions, 504 

on kidney, 414 

on liver disease, 384 

on pancreatic disease, 376 

on thigh disease, 453 

on thigh tumors, 454 
Stenosis, aortic, 239 

mitral, 220 

of a bronchus, 73, 286, 323 

pulmonary, 252 

tricuspid, 250 
Stethoscope, choice of, 138 

use of, 143 

varieties of, 138 
Stomach, 374 

cancer of, 382, 383 

cancer of, glands in, 30 

cancer of, statistics, 382 

cancer of, vomitus in, 383 

contents, acetic acid in, 380 

contents, acidity of, 379 

contents, blood in, 379 

contents, blood in, tests for, 379 

contents, chemical tests of, 380 

contents, color of, 379 

contents, determination of total 
acidity of, 380 

contents, free hydrochloric acid 
in, tests for, 380 

contents, general appearance, 
379 

contents, in achylia gastrica, 380 

contents, in fermentation, 380 



Stomach contents in stasis, 308 
contents, inspection of, 380 
contents, lactic acid in, 381 
contents, lactic acid in, test for, 

381 
contents, method of obtaining, 

379 
contents, mucus in, 380 
contents, nitric acid in, 380 
contents, normal quantity of, 379 
contents, odor of, 379 
contents, sediment in, 382 
contents, significance of organic 

acids in, 382 
contents, total acidity, 381 
dilatation of, 376 
dilatation of, causes and symp- 
toms, 383 
dilatation of, diagnosis, 384 
dilatation of, statistics of, 382 
diseases of, incidence and diagno- 
sis of, 382 
distention of, methods, 378 
estimation of size and position, 

376, 378 
fluid in, palpation of, 366 
hyperacidity in, 383 
hypoacidity in, 383 
hypogastric bulging of, 376 
inspection and palpation, 374 
methods of examination, 374 
normal splash sound in, 376 
passing of tubes, 376 
secreting and motor power of, 

376 
test meal for examination of, 377, 

379 
tumor in cancer of, 375 
ulcer of, statistics of, 382 
visible peristalsis in, 375 
washing of, method, 379 



572 



INDEX. 



Stomatitis, breath in, 21 

gangrenous, 26 
Stools in gastric ulcer, 383 

in jaundice, 14, 391 

in pancreatic disease, 395 
Strabismus, 16 
Stridor, respiratory, 521 
Strong}' loides intestinalis, 405, 410 
Strychnine poisoning, spasm in, 508 
Subsultus tendinum, 43 
Succussion, 169, 332 
Sugar, 426 (see Glusosuria) 
Sunstroke, coma in, 520 

fever in, 3 
Suppurations, chronic, anaemia in, 

476 
Sweat, in jaundice, 14 
Syncope, 519 

local, in Raynaud's disease, 49 
Syphilis, arthritis in, 493 

breath in, 21 

chancre of penis in, 443 

congenital, teeth in, 20, 21 

coryza in, 17 

dactylitis in, 48-50 

eruptions on forehead in, 9 

glands of neck in, 30 

hereditary, delayed closure of 
fontanels in, 6 

inguinal glands in, 452 

jaundice in, 391 

keratitis in, 16 

loss of hair in, 7 

mucous patches in, 18-25 

nodes on humerus in, 38 

nose in, 17 

of frontal bone, 7 

of liver, 388 

of lung, 323 

of tongue, 23 

orchitis in, 444 



Syphilis, palate in, 29 

periostitis in, 459 

periostitis, scars on forehead re- 
sulting from, 8 

ptosis in, 16 

sores about nails in, 52 

strabismus in, 16 

tonsils in, 27 
Syringomyelia, changes of nails in, 
52 

claw-hand in, 46 

felons in, 50 

Morton's disease in, 50 

with atrophic arthritis, 496 
Systolic murmur (see Murmur) 

Tabes dorsalis, ataxia in, 508 
dorsalis, knee-jerk in, 512 
dorsalis, optic neuritis in, 16 
dorsalis, paresthesia in, 510 
dorsalis, paraplegia in, 457 
dorsalis, reaction of pupil in, 15 
dorsalis, Romberg's sign in, 509 
dorsalis, sexual power in, 515 
dorsalis, sphincteric reflexes in, 

515 
ulcer of toe in, 463 
with atrophic arthritis, 496 
with contraction of pupil, 15 

Tachycardia, 261 

Tactile fremitus, 98, 297, 308, 318, 348 

Taenia saginata, 405, 406 
solium, 405, 407 
nana, 405, 408 

Tallqvist's test for haemoglobin, 464 

Tape-worm in faeces, 405-409 

Teeth, 20 

grinding of 21 

in congenital syphilis, 20 

in cretinism, 20 

in rickets, 20 



INDEX. 



573 



Teeth, time of appearance, 20 
Temperature, 2 

in myxcedema 3, 10 

in nephritis, 3 

in osteomyelitis, acute, 454 

in pathological conditions, 3 

in uncompensated heart disease, 
3 

malingering in, 2 

significance of, 2 

subnormal, 3 
Tenderness in general peritonitis, 371 

in intestinal diseases, 398 

in peritonitis, 371 
Tenosynovitis, 41 

of Achilles tendon, 461 
Tension of pulse, 108 
Testes, 444 

absence of one or both, 445 

cancer of, 444 

hematocele of, 445 

retained, 453 

sarcoma of, 444 
Tetany, spasms in, 46 
Thigh, 453 

cancer, metastatic, 455 

cramps in, causes of, 456 

diseases of, statistics on, 453, 454 

intermittent claudication of, 456 

meralgia, paresthesia of, 455 

miscellaneous lesions of, 455 

osteoma of, 454 

sarcoma of, 454 

significance of scars on, 454 

tumors of, statistics, 454 
Thoma-Zeiss blood counter, 473 
Thoracic aneurism (see A neurism) 

deformities, 62-68 

disease, 199-361 

disease, methods of diagnosis in, 
56-198 



Thorax, paralytic, 63 

tender points on, 102 
Thrill, 97 

in aortic aneurism, 282 

in aortic stenosis, 243 

in congenital heart lesions, 265, 
266 

in mitral regurgitation, 217 

in mitral stenosis, 222 

in pulmonary stenosis, 252 
Throat, in chickenpox, 27 

in diphtheria, 26 

in smallpox, 27 

in pharyngitis, 26 

in scarlet fever, 26, 27, 28 

methods of examination, 26 

with streptococcus infection, 27 
Thrombosis, oedema of arm in, 38 

of mesentery, 373 

of vein, 458 
Thrush, 27 
Thyroid gland, atrophy of, 31 

gland, malignancy of, 32 
Tissues, accumulation of fluid in, 1 
Tobacco, shaking of head in, 13 
Toe-drop gait, 506 
Toes, 463 

lesions of, 463 

tender, after typhoid fever, 463 
Tongue, 22 

cancer of, 23 

cancer of, glands in, 30 

canker of, 22 

coating of, 22 

cyanosis of, 22 

dry brown, 22 

fissures of, 23 

geographic, 23 

herpes of, 22 

hypertrophy of, 24 

in alcoholism, 22 



574 



INDEX. 



Tongue, in cretinism, 10, 24 

in dementia paralytica, 22 

in facial paralysis, 22 

in gastric fermentation, 22 

in hyperacidity or gastric ulcer, 
22 

in myxcedema, 24 

in typhoidal states, 22 

in weakness, 22 

indentation of, 22 

jaundice in, 22 

leukoplakia buccalis, 23 

syphilis of, 23 

tremor of, 22 

tuberculosis of, 23 

ulcers of, 23 
Tonometer, Gaertner's, 112 
Tonsil, abscess of, 28 
Tonsillitis, acute, 28 

follicular, 28 

with enlarged glands, 30 
Tonsils, 26 

enlargement of, 28 

general redness of, 26 

in adenoids, 28 

in diphtheria, 26, 27 

in leukaemia or pseudo-leukaemia, 
28 

in pharyngitis, 26 

in scarlet fever, 26, 27, 28 

malignant disease of, 27 ' 

membrane on, 27 

method of examination, 26 

sarcoma of, glands in, 30 

syphilitic ulcerations of, 27 

tuberculous ulcerations of, 27 

yellowish-white spots on, 27 
Topfer's reagent, 380 
Tophi, gouty, diagnosis of, 503 

in gout, test for, 488 
Torticollis, congenital, 32 



Torticollis with spasm, 32 
Toxaemia, fever in, 3 

in hepatic cirrhosis, 2 

in tuberculosis, 2 

in typhoid, 2 

leucocytosis in, 478 

tremor of hands in, 43 

with jaundice, 15 
Toxaemias, emaciation in, 2 
Tracheal tug, 283 
Tracheitis, 292 
Trans verse myelitis, anaesthesia in 

510 
Traube's semilunar tympanitic space, 

percussion of, 369 
Trauma, nosebleed in, 17 

scars on forehead resulting from, 
8 
Traumatic neuroses, paralysis in, 36 
Tremor, 508 
Tremors of hand, 43 

of hands in alcoholism, 44 

of hands in cold, 43 

of hands in fever, 43 

of hands in Graves' disease, 44 

of hands in hysteria, 44 

of hands in multiple sclerosis, 44 

of hands in nervousness, 43 

of hands in old age, 43 

of hands in paralysis agitans, 44 

of hands in toxaemia, 43 

of tongue, 22 
Trichiniasis, blood in, 479 

cedema of eyelids in, 14 

tenderness of leg in, 459 

symptoms of, 14 
Trichiuris trichiura, 405, 409 
Trichomonas intestinalis, 405 
Tricuspid disease, 188, 247-251 

regurgitation, 246 

stenosis, 250 



INDEX. 



575 



Trigeminal neuralgia, baldness in, 7 

Trophic disorders, 517 
disturbances, 48 

Trypanosomiasis, blood in, 479 
parasite in, 483 

Tuberculosis, arthritis in, 492 
dactylitis in, 48-50 
emaciation in, 2 
epididymitis in, 444 
in ankle bones, 461 
of belly wall, 367 
of bone of arm, 38-40 
of cervical glands, 30 
of hip, lordosis in, 54 
of knee, distinguished from sar- 
coma, 455 
of mediastinal glands, 524 
of nose, 17 
of omentum, 375 
of peritoneum, 370, 372 
of peritoneum, anaemia in, 372 
of peritoneum, emaciation in, 372 
of peritoneum, signs in, 372 
of sacro-iliac joint, 53 
of spine, 493 
of spine, lordosis in, 54 
of the lungs, 304-316, 532 
of the lungs, acute, 316 
of the lungs, advanced, 311 
of the lungs, cavity formation in, 

313 
of the lungs, chronic, 308-316 
of the lungs, cough in, 305, 306 
of the lungs, diagnosis of, 304- 

316 
of the lungs, emaciation in, 310 
of the lungs, fever in, 304 
of the lungs, hemorrhage in, 305 
of the lungs, hoarseness in, 305 
of the lungs, Litten's signs in, 
307 



Tuberculosis, of the lungs, physical 
signs in, 304, 316 
of the lungs, rales in, 306 
of the lungs, tuberculin in, 304 
of the lungs, with emphysema, 

315 
of tongue, 23 
of wrist joint, 40 
orchitis in, 444 
sores about nails in, 52 
spinal paraplegia in, 457 
tonsils in, 27 
vertebral, abscess in, 55 

Tuberculous peritonitis, ascites in, 
372 

Tug, tracheal, 283 

Tumors, 38 

abdominal, 78, 368 
abdominal, lordosis in, 54 
abdominal, respiratory move- 
ments of belly in, 364 
aneurismal, 281 
congenital, of back, 55 
in cancer of peritoneum, 372 
in cancer of stomach, 375 
in epigastrium, 375, 382 
in local peritonitis, 371, 372 
mediastinal, 290 
cedema of arm in, 38 
of back, 54 
of liver, 375 
of pancreas, 375 
of spine, 66 

Tympanites, pulmonary, 321 

Typhoid fever, breath in, 21 
fever, nosebleed in, 17 
fever, rose spots in, 363 
fever, spleen in, 412, 413 
fever, tender toes after, 463 
fever, toxaemia in, 2 
fever, Widal reaction in, 481 



576 



INDEX. 



Ulcer in tuberculous dactylitis, 49 

of }eg, 458 

of stomach, statistics of, 382 

of tongue, 23 

perforating, of toe, 463 
Uncinaria americana, 405, 407 

eggs of, 408 
Uncinariasis, blood in, 479 
Uraemia, aphasia in, 516 

breath in, 21 

distinguished from apoplexy, 518 
Urate of sodium in gouty deposits, 

501 
Urethra, abscess of, 443 

caruncle of, 447 

discharge from, 443 

glands, abscess of, 447 

stricture of, distended bladder 
in, 438 
Urine, acetone in, 428 

acute retention of, 438 

albumin in, 425, 426 

albumin in, Esbach's test, 424 

albumin in, significance of, 425, 
426 

albumin in, tests for, 424 

animal parasites in, 433, 434, 435 

bile in, 391 

blood in, 422, 431 

casts in, 429, 431 

chemical examination of, 423 

color of, 420 

crystals in sediment, 433 

diacetic acid in, 428 

diazo reaction, 428 

eggs of Bilharzia haematobium 
in, 410 

glucose in, 426 

glucose, Fehling's test for, 426 

glucose, fermentation test for, 
427 



Urine, in bladder disease, 439 

in cystitis, 421 

in diseases of pancreas, 395 

in jaundice, 14 

in kidney disease, 418, 423, 426 

in renal suppuration, 421 

optical properties of, 420 

overconcentration of, 439 

pus in, 421 , 432 

pus in, diagnosis of origin, 421, 
422 

reaction of, 423 

retention of, in acute prostatitis, 
439 

sediment of, 420 

sediment of, free cells in, 431 

sediment of, microscopic exami- 
nation of, 429 

sediments, significance of, 421 

shreds in, 420 

significance of free cells in, 432 

specific gravity of, 419 

spermatozoa in, 432 

total solids in, 419 

turbidity of, 420 

urate sediment in, 421 
Uterus, 447 

cancer of, 448 

endometritis, 448 

erosions of cervix, 447 

fibro-myoma of, 448 

lacerations of cervix, 447 

malpositions of, 447 

prolapse of, 447 
Uvula, 28 

Valgus, 460 

Valve areas, 171 

Valvular heart lesions, 210-256 

lesions, combined, 253 
Varicocele, 445 



INDEX. 



577 



Varus, 460 

Vascular phenomena, 87, 92 

phenomena in aortic regurgita- 
tion, 230-234 

sounds, 182, 183 

tension, 108 
Vasomotor disease, 517 
Veins, abdominal, 363 

inspection of, 88, 247 

pulsations in (see Pulsation) 

sounds in, 183 

thrombosis of, 458 

varicose, 458 
Ventricle, dilatation of, 209 

hypertrophy of, 206-208 
Ventricular septum, defects of, 266 
Vertebrae, cervical, dislocation of, 32 

deviations of, 33 

deviations of, due to habit or oc- 
cupation, 33 

deviations of, due to intracranial 
disease, 33 

deviations of, in astigmatism, 33 

when palpable, 366 
Vocal fremitus, 167-169 

fremitus, in pleurisy with effu- 
sion, 345, 348 • 

fremitus, in pneumonia, 298, 299 

fremitus, in pneumothorax, 332 

fremitus, in pulmonary tubercu- 
losis, 308, 311 

fremitus, spoken, 168 

fremitus, whispered, 167, 298, 
348 
Voice sounds (see Vocal fremitus) 
Vomiting, in gastric cancer, 382 

in gastric ulcer, 383 

in general peritonitis, 371 

in intestinal obstruction, 401 
Vomitus, "coffee-ground," 382 



Vulva, eczema of, 446 

oedema of, 446 

varicose veins, 446 
Vulvo- vaginitis, 446 

Wasting diseases, depressed fonta- 
nels in, 7 
Weeping sinew, 41 
Weight, gain in, 1 

in infectious fevers, 2 

in insomnia, 2 

in malnutrition, 2 

in myxcedema, 1 

in old age, 2 

in toxsemic states, 2 

increased after wasting diseases, 1 

increased in dropsy, 1 

loss of, 2 

physiological changes in, 2 
Weil's disease, jaundice in, 392 
Whooping-cough, blood in, 479 

oedema of eyelids in, 14 
Widal reaction in typhoid, 481 
Winking reflex, 515 
Wrist, enlargement of bones in pulmo- 
nary osteoarthropathy, 42, 43, 
47 

in atrophic arthritis, 47 
Wrist-drop in lead-poisoning, 36 
Wry-neck, 32 

X-ray in diagnosis of Pott's disease, 

493 
in hypertrophic arthritis, 499 
in joint examination, 487, 488- 

491, 492 

Yellow fever, with conjunctivitis, 14 
fever, jaundice of, 392 



37 



M. 




LIBRARY OF CONGRESS 



III 

029 827 753 



